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GENERAL  AND  LOCAL 


ANESTHESIA 


By  AIME  PAUL  HEINECK,  M.  D. 

Surgeon   to  Cook  County   Hospital;    Instructor  in   Clinical 
Surgery,  College  of  Physicians  and  Surgeons,  Med- 
ical Department  of  the  University  of  Illinois. 


'  The  medical  man  cannot  acquire  more  than  a  mere  rudi- 
mentary knowledge  of  anesthetizing  from  any  book, 
but  he  may  obtain  undoubted  service  therefrom, 
enabling  him  to  appreciate  the  dangers  incident  to, 
the  caution  necessary  in  anesthetizing  and  grasp  the 
rationale  of  the  various  methods  of  procedure  in  the 
administration  of  anesthetics."— Dudley  Buxton. 


f^V  V^  1^^ 

Second  Edition,  Revised  and  Enlarged. 

(^V  t^v  1^* 


CHICAGO : 
P.  Engelhard  &  Co. 
1901. 


Copyright  1901 
By  G.  P.  ENGELHARD  &  COMPANY. 


PREFACE. 

The  competent  anesthetist  is  the  surgeon's  most 
valuable  assistant.  Conscious  of  this  fact,  I  have 
endeavored  to  present  in  a  concise  form,  the  tech- 
nique of  surgical  general  and  local  anesthesia.  The 
book  could  have  been  made  more  academical,  could 
have  been  made  to  include  interesting  discussions 
of  as  yet  unsettled  points,  but  as  it  was  intended 
for  the  hospital  interne  and  for  the  general  prac- 
titioner I  decided  to  make  it  purely  practical. 
Points  that  admit  of  controversy  I  have  omitted. 
The  methods  that  I  have  outlined  are  methods  that 
are  sanctioned  by  European  and  American  clin- 
icians. They  are  methods  which  I  have  tested 
in  my  surgical  service  at  the  Cook  County  Hos- 
pital. 

The  induction  of  anesthesia  by  sub-arachnoi- 
dean  injections  of  cocaine  solutions  is  not  consid- 
ered in  this  edition.  The  procedure  is  still  in  the 
experimental  stage.  Before  it  can  be  adopted  by 
the  general  profession,  its  shortcomings  will  have 
to  be  remedied.  Its  great  disadvantage  is  its  un- 
reliableness. 

In  this  edition  I  present  a  large  amount  of  new 
matter  concerning  bromide  of  ethyl  as  an  anes- 
thetic and  discuss  a  number  of  important  reme- 


4  PREFACE. 

dies  used  for  local  anesthesia  which  were  not  con-  ' 

sidered  in  the  first  edition.     The  whole  book  has  ' 

been  rewritten  and  brought  up  to  date.  ; 

I  take  this  opportunity  of  thanking  the  attend-  j 

ants  of  the  medical  department  of  the  Newberry  \ 

Library  for  the  many  courtesies  which  they  have  i 

extended  to  me. 

Aime  Paul  Heineck. 

April  20,  1901. 


THIS    MONOGRAPH 
Is  dedicated  to 

Dr.  Chattnccy  "W.  Courtwright, 
As  a  token  of  gratude  and  esteem. 


CHAPTER  I. 

GENERAL  ANESTHESIA. 

Ether  and  chloroform  are  the  most  serviceable 
and  the  most  widely  used  agents  for  the  induction 
of  general  surgical  anesthesia.  General  surgical 
anesthesia  has  its  dangers.  No  powerful  general 
anesthetic  agent  is  free  from  risk.  There  is  always 
danger  in  the  use  of  a  general  anesthetic^  whatever 
may  be  the  indications  for  its  use.  Ether  and 
chloroform  are  highly  toxic  substances^  the  inhala- 
tion of  which  is  capable  of  producing  death.  All 
anesthetics  are  to  be  used  cautiously.  The  mor- 
tality, however,  that  attends  the  use  of  these  sub- 
stances is  largely  the  mortality  of  carelessness  and 
of  incompetency.  It  can  be  greatly  reduced  by 
observing  modern  safeguards  and  by  employing 
improved  methods  of  administration.  The  anes- 
thetist must  not  depend  upon  a  single  danger- 
signal.  He  must  know  them  all  and  have  a  clear 
understanding  of  their  relative  importance.  When 
death  occurs  from  the  administration  of  an  anes- 
thetic, very  frequently  it  is  due  to  lack  of  watch- 
fulness, to  ignorance,  and  had  proper  precautions 
been  taken,  it  would  not  have  taken  place.  Statis- 
tics prove  conclusively  that  the  element  of  danger 
with  either  chloroform,  ether  or  bromide  of  ethyl 
is  not  large  provided  the  anesthetist  be  competent. 


o  GENERAL    AND    LOCAL    ANESTHESIA. 

Upon  the  usefulness  of  general  surgical  anesthe- 
sia all  are  agreed.  Its  advantages  to  the  surgeon 
are  thus  summarized  by  Dr.  D.  W.  Cheever:  "He 
need  not  hurry;  he  need  not  worry;  he  need  not 
sympathize;  he  can  calmly  dissect,  heedful  only 
that  the  anesthetist  is  competent,  the  operation 
not  prolonged  beyond  the  verge  of  exhaustion;  he 
can  do  better  work;  he  can  pause  and  consider; 
he  can  choose  his  steps;  he  can  be  deliberate,  if 
not  dextrous.^"  In  many  cases  there  is  infinitely 
greater  danger  from  an  unskilled  anesthetist  than 
from  a  bungling  surgeon. 

For  the  surgeon  to  derive  all  the  forenamed 
advantages  from  the  use  of  anesthetics,  the  anes- 
thetist must  be  competent.  He,  the  anesthetist, 
must  know  the  physiological  action  of  the  agent 
which  he  is  administering.  He  must  be  cautious 
and  he  must  be  vigilant  in  its  administration.  He 
must  know^  the  danger  signals  of  surgical  anesthe- 
sia. He  must  also  know  all  the  procedures  by  the 
aid  of  which  the  grave  accidents  of  anesthesia  can 
be  forestalled  and  combated. 

As  the  success  and  progress  of  surgery  depend 
in  a  large  measure  upon  the  safety  of  anesthesia, 
it  is  evident  that  too  much  study  can  not  be  given 
to  this  subject.  An  operation  may  be  practically 
devoid  of  danger,  while  an  anesthetic  is  never 
administered  without  imperiling  the  life  of  the 
patient.     Though  much  has  been  written  on  this 


NECESSITY    OF    UNDERSTANDING   ANESTHESIA.  9 

subject,  though  the  subject  is  old.  Dr.  McBurney 
speaks  truly  when  he  says:  ''Very  few  medical 
men  administer  ether  well/'  As  to  chloroform, 
many  physicians,  conscious  that  they  do  not  know 
how  to  administer  it,  and  not  possessing  the  neces- 
sary ambition  and  energy  to  acquire  the  knowl- 
edge, never  make  use  of  it.  Many  that  use  it, 
use  it  faultily.  Lord  Lister  says:  "Death  from 
chloroform  is  almost  always  due  to  faulty  admin- 
istration." It  is  easy  to  become  a  competent  anes- 
thetist, and  it  is  the  duty  of  every  medical  prac- 
titioner to  become  one.  Anesthetics  being  used 
in  all  the  different  departments  of  medicine,  it  is 
imperative  that  all  physicians  should  know  how  to 
skilfully  administer  ether  and  chloroform. 

X^nowledge  is  only  acquired  by  observation  and 
by  study.  To  become  a  good  anesthetist,  one 
must  be  taught,  and  must  learn,  how  to  induce  and 
how  to  maintain  surgical  anesthesia.  Theoretical 
and  practical  knowledge  are  both  required.  The 
value  of  theoretical  knowledge  lies  greatly  in  the 
fact  that  more  attention  is  paid  to  useful  practical 
details,  if  the  philosophy  underlying  their  utility 
is  evident  or  is  known. 

The  giving  of  an  anesthetic  should  never  be 
delegated  to  a  nurse,  much  less  to  a  layman. 
Nurses,  owing  to  their  incomplete  medical  educa- 
tion, of  necessity,  are  irresponsible  anesthetists. 
They  should  not  undertake  and  should  not  be 


10  GENERAL    AND     LOCAL    ANESTHESIA. 

asked  to  discharge  the  duties  of  a  medical  prac- 
titioner. The  giving  of  an  anesthetic  requires  the 
undivided  attention  of  an  educated  and  watchful 
physician.  It  requires  accurate  knowledge.  It 
demands  the  closest  application.  The  surgeon 
must  not  "start  the  anesthetic'^  and  then  entrust 
the  continuance  and  the  maintenance  of  the  anes- 
thesia to  an  unqualified  bystander.  Accidents 
occur  during  all  the  different  stages  of  anesthesia, 
and  must  be  immediately  met  by  appropriate 
measures,  so  as  not  to  prove  fatal. 

Never  should  the  surgeon  administer  chloroform 
or  ether,  and  operate  at  the  same  time.  It  is  false 
economy.  There  is  no  scarcity  of  physicians.  It 
is  unsafe.  Deaths  have  been  caused  by  this  prac- 
tice. By  attempting  to  do  two  things  at  once,  the 
surgeon  does  neither  well.  The  anesthetic  is  not 
watched  as  it  should  be  watched.  The  anesthetist's 
eye  'should  never  be  off  his  patient  during  the 
entire  duration  of  the  anesthesia.  Asepsis,  of 
necessity,  will  be  deficient.  The  neglect  of  aseptic 
teachings  invites  suppuration  with  its  train  of 
annoyances.  His  mind  will  not  be  concentrated 
upon  the  technique  of  the  operation,  hence  the 
surgical  methods  employed  will  be  at  fault  and 
results  will  not  be  ideal. 

An  anesthetic  should  not  be  given  if  the  patient 
refuses  to  be  anesthetized.  Should  the  patient's 
mental  condition  be  such  as  to  unfit  him  for  pass- 


/.  USED    FOR    DIAGNOSTIC    PURPOSES.  11 

ing  on  the  advisability  of  anesthesia^  the  consent 
of  his  relations  or  his  friends  mnst  be  obtained. 
In  emergency  cases  if  the  patient  be  unconscious 
and  in  the  absence  of  friends  and  relatives,  the 
surgeon  may  take  the  responsibility  of  adminis- 
tering the  anesthetic. 

Indications  for  the  use  of  ether  or  chloroform 
anesthesia  are: 

1.  Foe  Diagnostic  Pueposes:  (a)  In  com- 
plete exploration  of  rectum,  or  genitourinary 
organs;  (b)  in  children,  in  exploring  the  bladder 
for  stone,  since  in  children  the  bladder  is  so  sensi- 
tive that  it  empties  itself  when  an  instrument  is 
introduced;  (c)  in  obscure  abdominal  and  pelvic 
conditions,  a  precise  diagnosis  not  being  otherwise 
obtainable,  as  in  carcinoma  ventriculi,  as  in  gyne- 
cological conditions,  such  as  pus-tubes,  etc. 
"Examinations  under  anesthesia  can  be  conducted 
with  a  thoroughness  which  is  impossible  without 
it;  the  uterus  can  be  drawn  down,  adhesions  pulled 
upon,  perineum  deeply  invaginated  and  inflamed 
tubes  and  ovaries  handled  in  a  way  which  is  im- 
possible so  long  as  the  patient  remains  conscious" 
(Kelly,  Baltimore);  (d)  it  may  be  used  to  exclude 
hysterical  conditions — ^hysterical  joint,  pseudocye- 
sis,  etc.;  (e)  to  exclude  simulation. 

Eotterstein  reports  the  case  of  a  military  officer 
who  simulated  aphonia,  so  as  to  secure  his  dis- 
charge from  the  army.    While  being  anesthetized, 


12  GENERAL    AND    LOCAL    ANESTHESIA. 

in  the  stage  of  excitement,  lie  began  to  sing.  He 
was  not  discharged  from  the  army,  (f)  In  many 
cases,  it  is  only  by  means  of  narcosis  that  we  can 
obtain  a  sufficiently  satisfactory  view  of  the  eyes. 
In  blepharospasm,  especially  in  children,  by  pro- 
ceeding with  violence,  there  is  danger  of  abrading 
the  eyeballs.  This  is  especially  to  be  feared  in 
purulent  ophthalmia  and  in  corneal  ulceration. 
In  adults,  cocaine  anesthesia  is  often  sufficient. 
Anesthesia  is  of  value  as  an  aid  to  diagnosis, 
because  by  it  insensibility  to  pain  on  the  part  of 
the  patient  is  secured,  and  through  it,  also,  com- 
plete muscular  relaxation  is  obtained.  Complete 
muscular  relaxation  is  especially  valuable  in  the 
diagnosing  of  fractures  and  of  abdominal  and 
pelvic  pathological  conditions.  Examinations 
under  it  can  therefore  be  more  prolonged,  more 
deliberate,  more  accurate.  All  resistance,  volun- 
tary and  involuntary,  on  part  of  the  patient  is 
done  away  with. 

2.  For  Theeapeutic  Pueposes:  In  spasm, 
convulsions  (epilepsy,  puerperal  eclampsia^  tetan- 
us), very  painful  neuralgias  (tic  douloureux,  visce- 
ralgia of  neurasthenia),  renal  colic,  hepatic  colic, 
intestinal  colic.  Tournier  (Belfort)  employs  ether- 
ization in  the  treatment  of  hysteric  and  hystero- 
epileptic  convulsions  occurring  in  children  and  in 
adults. 


•  ,.  ANESTHETICS    IN    OBSTETRICS.  13 

The  anesthesia  is  used  to  abort  the  spasms  or 
convulsions.  "In  epileptic  attacks,  every  effort 
should  be  made  to  lessen  the  liability  of  danger  to 
the  patient  from  the  violence  of  the  spasms.  One 
is  at  times  Justified  to  nse  ether  or  chloroform  by 
inhalation  to  control  the  severity  of  the  convul- 
sions." (Anders.)  In  the  other  conditions,  we  have 
recourse  to  anesthesia  when  the  suffering  is  beyond 
the  influence  of  safe  doses  of  morphine.  In  these 
conditions,  we  only  administer  chloroform  till 
relief  of  pain  occurs. 

3.  Ly  Obstetrics.  (A)  In  labor,  we  employ 
anesthetics  to  mitigate  the  suffering  of  natural 
labor,  to  secure  a  semianesthesia,  that  is  an 
analgesia,  a  marked  diminution  of  pain  in  the 
uterine  and  the  periuterine  regions.  Winckel 
states  that  general  anesthetics  render  great  service 
when  the  cervix  is  almost  dilated  and  when  the 
presenting  part  begins  to  pass  through  the  vulva. 
We  use  them  in  natural  labors  in  primiparse  who 
are  nervous  and  excitable  and  in  whom  the  pain 
may  even  cause  delirium;  in  all  cases  in  which 
there  is  a  spasmodic  contraction  or  rigidity  of  the 
neck  or  body  of  the  uterus. 

The  following  conditions  contraindicate  their 
use:  Opposition  of  the  patient  to  their  use; 
absence  of  severe  suffering;  placenta  previa; 
alcoholism;  marked  disease  of  the  circulatory  or 
respiratory  apparatus. 


14  GENERAL    AND    LOCAL    ANESTHESIA. 

AN^ESTHETICS     IX     CHILDBIKTH. 

The  following  facts  as  to  the  use  of  anesthetics 
in  childbirth  are  established: 

a.  Chloroform  is  the  agent  sanctioned  by  almost 
all  the  authorities.  It  is  pleasant  to  take.  It  acts 
quickly.  Ether  is  disagreeable  to  take,  is  slow  of 
action.  Ethyl  bromide  has  irritating  properties, 
a  disagreeable  odor  and  interferes  with  the  pains. 
It  should  not  be  used  in  obstetrics.  It  is  not  a 
safe  anesthetic  for  prolonged  intermittent  use. 
Chloroform,  unlike  ether,  is  not  inflammable. 
Hence,  it  can  be  used  at  night,  without  any  danger 
from  light  or  fire.  And  certainly  it  is  at  night 
that  the  largest  number  of  obstetrical  cases  occur. 
When  using  chloroform,  in  a  room  illuminated  by 
coal-gas,  for  your  personal  and  for  the  patient's 
safety,  see  that  the  room  is  properly  ventilated. 

b.  Chloroform  should  be  administered  at  the 
beginning  of  each  pain,  and  discontinued  as  soon 
as  the  pain  has  passed,  then  resumed  at  beginning 
of  next  pain,  discontinued  at  close  of  pain  and 
so  on.  Never  should  complete  insensibility  be 
obtained.  The  object  sought  in  natural  labor  is  a 
mitigation  of  the  pain^  a  semianesthesia.  Com- 
plete anesthesia  would  interfere  with  the  progress 
of  labor. 

c.  Anesthetics  are  not  harmful  to  the  child. 
Anesthesia  of  the  child  is  not  produced.  They 
are  not  harmful  to  the  mother.    "Lactation  is  not 


ANESTHETICS   IN   CHILDBIRTH.  15 

injuriously  affected,  nor  is  the  child  in  any  way 
injured."  (Buxton.)  The  almost  complete  immu- 
nity enjoyed  by  the  woman  in  childbirth,  from 
the  accidents  of  anesthesia,  is  partly  due  to  the 
following  conditions:  Marked  hypertrophy  of  the 
left  ventricle  during  pregnancy;  recumbent 
posture  which  patient  naturally  assumes  during 
delivery;  action  of  the  heart  is  aided  by  the  alter- 
nate relaxations  and  contractions  of  the  uterus;  the 
tendency  of  anesthetics  is  to  produce  anemia  of 
the  brain.  This  anemia  is  counteracted  by  the 
labor-pains  which  give  rise  to  an  engorgement  of 
that  organ.  Pain  is  a  stimulant  to  the  vaso-motor 
system,  and,  consequently,  there  is  less  danger  in 
anesthesia  while  labor-pains  are  in  progress. 
(Hare.) 

Anesthetics  do  not,  provided  the  narcosis  be  not 
too  profound,  interfere  with  the  uterine  contrac- 
tions. They  do  not  interfere  with  the  contractions 
of  the  abdominal  muscles.  They  weaken  the 
resistance  of  the  perineal  muscles.  They  are  of 
distinct  advantage  to  the  mother  because  by  their 
attenuation  of  pain  the  progress  of  labor  is 
hastened  [this  fact  is  especially  demonstrable  in 
women  that  fear  pain];  because  they  calm  the 
extreme  agitation  and  cerebral  excitement  that 
labor  often  produces  in  very  nervous  women,  and 
because,  by  shortening  labor,  they  lessen  its  trau- 
matisms, greatly  diminish  the  parturient^s  pros- 


16  GENERAL    AND    LOCAL    ANESTHESIA. 

tration,  and  make  her  recovery  more  rapid.  Car- 
diac, pulmonary  and  renal  lesions  are  not  absolute 
contraindications  to  their  nse  in  difficult  labors. 
Ether  would  doubtless  be  less  dangerous  to  a  dam- 
aged heart,  and  cause  less  shock  to  the  nervous  and 
vascular  systems,  than  would  the  agony  of  a  severe 
extraction  such  as  would  occur  with  an  excessively 
large  fetal  head  or  a  small  maternal  pelvic  outlet. 
(E.  H.  Eoot.) 

After  profound  anesthesia  during  delivery, 
increased  watchfulness  against  hemorrhage  is 
enjoined  by  most  teachers.  Playfair  believes  that 
the  use  of  anesthetics  increases  the  tendency  to 
hemorrhage.  This  tendency  to  hemorrhage  is 
disputed  by  many  good  authorities.  Fordyce 
Barker,  of  New  York,  says:  "Through  a  long 
number  of  years  I  have  rarely  attended  labors 
without  ether.  I  have  never  seen  from  it  any  ill 
effects.  Especially  has  it  not  caused  a  tendency 
to  hemorrhage." 

(B)  In  eclampsia  (puerperal)  to  abort  the  con- 
vulsions. 

(C)  In  all  obstetrical  operations  as:  Version, 
application  of  forceps  and  extraction  by  embry- 
otomy, etc. 

In  all  obstetrical  operations  the  anesthesia  must 
be  complete,  must  be  surgical,  not  obstetrical. 
In  obstetrics,   if   surgical,   and  not   obstetrical 


•   '  ANESTHETICS    IN    SURGURY.  17 

anesthesia  is  indicated,  you  will  be  governed  in 
your  choice  of  anesthetic  agent  by  the  same  rules 
that  obtain  in  the  absence  of  the  pregnant  con- 
dition. For  instance,  if  the  patient  has  a  cardiac 
lesion,  use  ether  instead  of  chloroform;  if  there 
is  a  marked  renal  lesion,  use  chloroform  and  not 
ether. 

ANESTHETICS     IN     SUKGERY. 

In  all  cases  in  which  there  is  an  indication  for 
surgical  anesthesia  and  the  condition  of  the  tissues 
or  the  nature  of  the  operation  do  not  admit  of  the 
employment  of  local  anesthetics,  we  have  recourse 
to  general  anesthetics.  We  use  ether  or  chloroform 
for  all  operations  requiring  a  longer  and  deeper 
anesthesia  than  can  be  obtained  by  nitrous  oxide 
gas  or  bromide  of  ethyl. 

There  are  no  absolute  contraindications  to  the 
induction  of  general  surgical  anesthesia.  When 
the  physical  condition  of  the  patient  permits  the 
performance  of  an  operation,  it  permits  of  the 
giving  of  an  anesthetic.  The  question  to  be 
decided  is  whether  the  disadvantages  attending  the 
use  of  the  anesthetic  more  than  counterbalance 
the  advantages  of  its  employment. 

There  are,  however,  unfavorable  conditions.  No 
age,  no  sex,  no  climate  confers  immunity  from 
the  dangers  of  ether  and  chloroform  anesthesia. 
Pregnancy  and  menstruation  do  not  contraindi- 


18  GENERAL    AND    LOCAL    ANESTHESIA. 

cate  ether  or  chloroform  anesthesia.  They  may, 
however,  eontraindicate  the  operation.  I  have 
not  found  a  single  case  reported  in  which  the 
induction  of  surgical  anesthesia  has  caused  abor- 
tion. 

In  the  following  conditions  the  giving  of  an 
anesthetic  is  hazardous,  because  experience  has 
taught  us  that  patients  suffering  from  these 
conditions  are  subject  to  the  grave  dangers  and 
accidents  of  anesthesia: 

In  patients  having  severe  organic  lesions  of  the 
central  nervous  system,  of  the  pulmonary  system, 
of  the  circulatory  system;  in  delirium  tremens, 
the  different  neuroses  as  epilepsy,  hysteria,  etc.;  in 
aneurisms  of  the  arch  of  the  aorta  or  the  innominate 
artery,  because  there  is  danger  of  vascular  rupture 
or  because  death  frequently  occurs  from  its  admin- 
istration in  this  condition;  in  surgical  shock;  in 
cachexia  from  any  cause,  fever,  prolonged  suppu- 
ration, suffering  from  intense  and  constant  pain. 
"These  conditions  bring  such  changes  in  tissue 
nutrition  and  tissue  vigor  as  to  render  the  action 
of  ether  and  chloroform  for  the  time  being  abnor- 

mal.^^  (Gill,  St.  Barthol.  Hosp.  Eep.,  London, 
1895.) 

SELECTIOJs^     OF     THE     ANESTHETIC. 

The  following  statistics,  being  the  combined 
statistics  of  Gurtl  of  Berlin  and  of  Juillard  of 


',  .  SELECTION   OF   THE  ANESTHETIC.  19 

GeneA^a,   show  that   chloroform  and   ether  have 

each  their  mortality: 

Anesthetic  Used.       Adm.  Deaths. 

Chloroform 691,319         224,  or  1  in    3,082 

Ether 341,058  23,  or  1  in  14,828 

Despite  the  unfavorable  showing  made  in  the 
above  figures  by  chloroform,  from  the  standpoint 
of  safety  as  compared  to  ether,  chloroform  main- 
tains its  popularity,  its  advocates  declaring  that  in 
competent  hands  it  is  preferable  to  ether,  because 
it  is  less  disagreeable  to  take,  less  irritating  to  the 
lungs,  its  stage  of  excitement  is  shorter,  and  its 
after-effects,  such  as  nausea  and  vomiting,  less 
annoying,  less  prolonged  than  those  of  ether. 
"N'ausea  and  general  depression  are  more  pro- 
nounced after  the  use  of  ether  than  after  the  use 
of  chloroform."  (Hare.)  Ether  and  chloroform 
have  each  their  individual  contraindications. 
Clinical  experience  teaches  us  that  the  mortality 
from  anesthesia  can  be  much  diminished  by  the 
careful  selection  of  the  anesthetic  in  each  indi- 
vidual case.  This  selection  is  to  be  arrived  at  by 
a  consideration  of  the  age  of  patient,  of  the 
climate,  of  the  environments,  of  the  physical  con- 
dition of  the  patient,  of  the  nature  of  the  opera- 
tion, of  the  posture  of  the  patient,  of  his  idiosyn- 
crasies, and  of  the  skill  of  the  anesthetist. 

This  is  the  only  scientific  method  of  procedure. 
Failure  to  do  this  will  at  times  be  followed  by  fatal 


20  GENERAL    AND     LOCAL    ANESTHESIA. 

accidents.  In  the  absence  of  indications  (which 
are  to  be  later  enumerated)  for  the  use  of  chloro- 
form, ether  is  the  anesthetic  to  use.  The  contra- 
indications to  the  use  of  chloroform  furnish  indi- 
cations for  the  nse  of  ether.  The  following  quota- 
tions from  eminent  experimental  therapeutists  and 
from  well-known  snrgeons  uphold  this  view: 

"Ether  is  by  far  the  safest  anesthetic  substance 
for  nse  during  prolonged  surgical  operations." 
(Hare.)  "Chloroform  is  seven  times  as  dangerous 
as  ether."  (Waller.)  H.  C.  Wood  urges  the  gen- 
eral use  of  ether,  and  adds :  "In  the  selection  of  an 
anesthetic,  the  question  of  safety  is  paramount.*' 
"I  amx  certain  that  ether  is  infinitely  safer  than 
chloroform."     (Frederick  Treves.) 

AGE     OF     PATIENT. 

In  children,  previous  to  the  age  of  seven  years, 
chloroform  is  the  safest  anesthetic.  The  relative 
immunity  of  children  to  chloroform  narcosis  is  due 
to  the  great  vascularity  of  their  nervous  system. 
The  percentage  of  chloroform  mortality  in  chil- 
dren is  much  below  that  of  older  patients.  In 
children,  ether  causes  a  great  outflow  of  bronchial 
mucus.  This  mucus  can  asphyxiate  the  patient.  The 
bronchial  mucous  membrane  of  children  is  delicate 
and  predisposed  to  inflammatory  processes.  Ether 
is  a  direct  irritant  to  these  mucous  surfaces  and 
can,  and  often  does,  excite  inflammation  of  the 
air  passages. 


CLIMATE   AND    ENVIRONMENTS. 


21 


As  a  general  rule,  ether  should  not  be  admin- 
istered to  patients  over  sixty  years  of  age,  because 
these  patients,  as  a  class,  either  suffer  from  or  are 
on  the  verge  of  renal  and  of  pulmonary  degenera- 
tive changes.  Ether  is  contraindicated  in  renal 
and  in  pulmonary  affections. 

CLIMATE. 

In  warm  climates  use  chloroform.  It  would 
seem  that  the  warm  atmosphere  of  tropical  cli- 
mates causes  a  rapid  action  of  the  chloroform  and, 
at  the  same  time,  its  rapid  evaporation.  Lawrie 
records  45,000  chloroformizations  without  a  death. 
A  warm  climate  renders  chloroform  vapor  more 
diffusable  and  so  lessens  its  noxious  effects.  The 
respiratory  functions  are  not  so  paramount,  owing 
to  the  great  activity  of  the  hepatic  and  cutaneous 
functions  in  warm  climates.  Ether  is  obtained 
and  preserved  with  difficulty  in  tropical  countries. 

ENVIKONMENTS. 

On  the  battlefield  and  in  the  navy,  chloroform 
is  the  anesthetic  to  use.  It  is  less  bulky.  The 
quantity  of  chloroform  needed  to  anesthetize  a 
patient  is  less  voluminous  than  the  quantity  of 
ether  required  for  the  same  purpose.  Ether  is 
inflammable,  chloroform  is  not.  It  produces  anes- 
thesia in  less  time  than  ether.  The  amount  of 
work  to  be  performed  being  great,  time  is  an 
important  factor. 


22  GENERAL    AND    LOCAL    ANESTHESIA. 

When  the  thermo-cautery  is  to  "be  used  ahout 
the  face,  use  chloroform. 

In  operations  by  gaslight,  use  chloroform.  Ether 
is  inflammable  and  explosive.  This  fact  should 
always  be  borne  in  mind,  because,  during  an  oper- 
ation, a  lighted  candle  or  gas  jet  brought  near  the 
ether  may  cause  a  serious  explosion.  The  danger 
of  using  ether  near  a  lighted  gas  jet  is  shown  by 
numerous  news  items. 

PHYSICAL     CONDITION     OF     PATIENT. 

(a)  In  atheromatous  conditions  of  the  blood- 
vessels, use  chloroform,  because  ether  produces  a 
more  violent,  a  more  prolonged  stage  of  excite- 
ment, thereby  increasing  the  liability  to  vascular 
rupture  and  its  consequences.  Ether  increases  the 
heart  action  and  raises  the  blood  pressure,  and 
hence  is  liable  to  cause  hemorrhage  from  weakened 
blood-vessels. 

(b)  In  organic  cardiac  lesions,  always  select 
ether.  In  this  connection,  we  must  always  remem- 
ber that  the  integrity  of  the  muscular  structure  of 
the  heart  is  of  far  greater  importance  than  the 
integrity  of  the  valves.  We  select  ether  because 
chloroform  is  a  powerful  cardiac  depressant  and 
paralj^zant;  because  chloroform  acts  upon  the 
heart;  it  causes  a  marked  depression  of  the  cardiac 
muscle,  involving  a  reduction  of  its  tone,  a  relaxa- 
tion of  the  cardiac  walls,  and  an  impairment  of  its 


CONDITION    OF   THE   PATIENT.  23 

functional  activity.  (McWilliam,  British  Med.  J., 
1890);  because  ether  is  a  cardiac  stimulant; 
because  experiments  and  clinical  observation  show 
that  chloroform  kills  generally  by  syncope  (Ver- 
neuil),  and  organic  cardiac  lesions  by  their  very 
nature  predispose  to  this  accident.  Sudden  arrest 
of  the  heart's  action,  from  structural  disease,  may 
take  place  during  the  first  few  minutes  of  chloro- 
form anaesthesia;  and  because  failure  to.  select 
ether  is  liable  to  result  in  accidents.  Should,  how- 
ever, the  cardiac  lesion  be  accompanied  by  marked 
bronchial  or  pulmonary  congestion,  use  chloro- 
form. 

If  a  fluidram  of  ether  be  injected  directly  into 
the  jugular  vein  of  a  dog,  there  is  no  fall  in 
arterial  pressure;  if  twenty  drops  of  chloroform 
be  injected,  it  will  immediately  cause  a  fatal 
paralysis  of  heart.  Sphygmographic  tracings  show 
that  ether  exerts  a  stimulant  action  upon  the  heart. 
They  also  show  that  chloroform  exerts  an  opposite 
action.  A  small,  weak  and  compressible  pulse 
grows  stronger  under  ether. 

In  renal  affections  use  chloroform,  because 
quantity  for  quantity  ether  is,  of  course,  less 
irritating  to  the  kidneys,  but  as  a  very  much 
larger  quantity  of  ether  than  of  chloroform  is 
needed  to  produce  anesthesia,  chloroform  is  to  be 
preferred.  The  effect  of  chloroform  anesthesia  on 
Jiidneys  is  practically  nil.    Drs.  Thompson  and 


34  GENERAL    AND    LOCAL    ANESTHESIA. 

Kemp,  who  have  made  experimental  researches 
upon  the  eircnlation  of  the  kidneys,  regard  chronic 
renal  disease  or  the  pressure  of  any  of  the  systemic 
signs  of  renal  inadequacy,  snch  as  rigid  arteries, 
high  tension  pulse  and  dilated  right  heart  with 
chronic  bronchitis,  as  contraindications  to  the  use 
of  ether,  and  if  any  general  anesthetic  has  to  he 
employed,  advise  the  use  of  chloroform. 

In  an  examination  of  fifty  cases  before  and  after 
etherization  (urine  filtered  and  nitric  acid  test 
used),  thirty-six  cases  showed  that  ether  either 
produced  albumin  or  increased  its  quantity  Avhen 
it  was  present  before.  (Blake.)  Ether  may  cause 
oliguria,  anuria,  or  nephritis. 

OTHEK     COXDITIOXS. 

In  diabetes  mellitus,  use  chloroform.  The  use 
of  ether  in  diabetic  patients  has  been,  followed  by 
diabetic  coma.    (Hare,  Da  Costa.) 

In  inflammatory  conditions  of  the  upper  and  the 
lower  respiratory  organs,  as  rhinitis,  laryngitis, 
tracheitis,  bronchitis,  pneumonia,  asthma,  emphy- 
sema, use  chloroform,  because  ether  is  a  distinct 
irritant  to  mucous  membranes  of  the  respiratory 
passages  and  because  untoward  efi^ects  of  ether  are 
mainly  exercised  upon  the  respiratory  system. 
(Sajous.) 

When  there  is  a  susceptibility  to  pulmonary 
inflammations,  use  chloroform. 

In  phthisis  pulmonalis,  use  chloroform. 


SELECTION    OF   ANESTHETIC.  25 

In  collapse,  especially  that  following  the  loss  of 
blood  in  shock,  as  characterized  by  low  tempera- 
ture, in  asthenia,  cachexia  and  in  anemia,  nse  ether 
(but  use  it  sparingly),  because  ether  has  stimu- 
lating properties,  and  because  a  comparatively 
small  dose  of  chloroform  may  produce  alarming 
or  fatal  cardiac  depression. 

In  alcoholics,  if  the  condition  of  the  heart  per- 
mits, use  chloroform.  Alcoholics  are  so  steeped 
in  stimulants  that  large  quantities  of  ether  must 
be  employed  to  secure  anesthesia,  and  even  then 
m.ay  be  ineffective. 

When  the  liver  function  is  impaired,  use  ether. 

In  obese  and  plethoric  individuals,  use  chloro- 
form. Ether,  by  causing  marked  engorgement  of 
the  upper  air  passages,  and  increased  secretion  of 
saliva  and  mucus,  renders  respiration  difficult. 

In  goitre,  and  in  all  conditions  tending  to 
reduce  the  caliber  of  larynx,  trachea  or  bronchi, 
as  malignant  disease  of  throat  and  neck^  deep 
cervical  cellulitis,  foreign  bodies  in  the  air 
passages,  foreign  bodies  in  the  esophagus,  asthma, 
etc.,  use  chloroform,  if  local  anesthesia  be  imsuit- 
able. 

In  empyema,  chronic  pleural  disease,  with  or 
without  marked  secondary  pulmonary  changes, 
use  chloroform. 

In  all  conditions  causing  such  narrowness  of 
upper  air  passages  as  to   produce  temporary  or 


26 


GENERAL    AND    LOCAL    ANESTHESIA. 


abiding  difficulty  in  breathing,  as  tumors  of  soft 
palate,  larnygeal  disease,  aneurism  pressing  on 
trachea,  use  chloroform. 

Hare  prefers  to  use  ether  in  young  athletes, 
for  clinical  experience  shows  that  this  class  of 
patients  are  especially  liable  to  accidents  with 
chloroform. 

NATUKE     OF    OPEKATION". 

A.  Use  chloroform  in  prolonged  operations 
about  the  mouth,  nose  and  pharynx,  when  mouth 
and  nose  must  frequently  be  uncovered,  because, 
owing  to  the  fact  that  consciousness  rapidly  re- 
turns when  the  supply  of  ether  is  discontinued,  its 
(ether^s)  intermittent  use  does  not  give  enough 
time  for  prolonged  surgical  procedure. 

B.  Always  give  chloroform  when  the  anesthetic 
is  to  be  given  through  a  tracheal  canula. 

C.  In  ophthalmology,  use  chloroform.  Ether, 
by  causing  struggling  and  venous  congestion, 
increases  the  risk  of  hemorrhage.  Its  after-effects, 
as  vomiting,  etc.,  also  disqualify  its  use  in  ophthal- 
mic work. 

D.  Use  chloroform  for  tracheotomy,  if  local 
anesthesia  prove  ineffective;  also  for  esophagotomy 
and  in  laryngeal  operations. 

E.  Use  chloroform  in  operations  in  which 
venous  engorgement  constitutes  a  serious  diffi- 
culty, as  in  removal  of  glands  at  root  of  neck; 
tracheotomy;    operations  on  brain  and  its  mem- 


NATURE   OF   OPERATION.  27 

branes,    etc.;   with   ether  the   venous    system  is 
engorged  and  incised  parts  bleed  freely.    (Hewitt.) 

F.  In  cranial  operations,  in  functional  or  organic 
diseases  of  the  brain,  use  chloroform.  Ether  pro- 
duces engorgement  of  the  cerebral  vessels,  and 
general  engorgement  of  the  venous  circulation.  By 
using  chloroform  we  shorten  the  stage  of  excite- 
ment and  lessen  the  tendency  to  hemorrhage. 

G.  In  abdominal  operations,  use  chloroform. 
"In  abdominal  surgery  chloroform  is  better  than 
ether."  (Kelly,  Baltimore.)  Eespiration  is  much 
quieter  under  chloroform  than  under  ether.  En- 
gorgement of  part  is  considerably  less,  hence  less 
hemorrhage.  Muscular  relaxation  is  more  com- 
plete. Eelaxation  of  the  abdominal  parietes  is  very 
important  in  abdominal  operations.  In  some  cases, 
ether  fails  to  secure  this.  The  tendency  of  patient 
to  cough  and  strain  is  considerably  less  after 
chloroform  than  after  ether.  Chloroform  is  less 
frequently  followed  by  vomiting.  Ether  increases 
the  bronchial  secretions.  The  stagnation  of  these 
in  the  bronchi  can  excite  pathological  conditions. 
After  abdominal  operation,  the  expelling  power 
by  which  the  bronchi  are  emptied  is  lessened, 
owing  to  the  inhibition  by  pain  and  by  the  incision 
of  the  abdominal  muscles.  Chloroform  does  not 
increase  the  bronchial  secretions,  and  hence  is 
comparatively  free  from  bronchial  or  pulmonary 
after-effects. 


28  GENERAL    AND    LOCAL    ANESTHESIA. 

H.  Chloroform  is  used  in  obstetrics,  and  in 
hepatic  and  renal  colic.  Its  action  is  quick.  It  is 
less  disagreeable  to  take. 

I.  In  operating  upon  the  neck,  use  chloroform. 
There  is  less  movement  of  the  parts.  Ether,  bj' 
provoking  copious  salivary  and  bronchial  secre- 
tions, hampers  respiration  and  renders  it  jerky.  ,. 

J.  Chloroform  should  never  be  used  for  extract- 
ing teeth.  K'itrous-oxide  gas  is  a  safe  and  con- 
venient anesthetic,  and  fulfills,  with  very  few 
exceptions,  all  the  requirements  of  the  dentist.  In 
Lyman's  collection  of  deaths  from  chloroform 
anesthesia  (393  in  number)  there  are  thirty  deaths 
that  occurred  under  chloroform  anesthesia  induced 
for  removal  of  teeth. 

K.  Chloroform  should  not  be  used  for  minor 
operations,  such  as  removal  of  ingrowing  toe-nail, 
opening  of  superficial  abscess,  or  when  local  anes- 
thesia fulfills  the  requirements.  "A  very  large 
proportion  of  deaths  from  chloroform  anesthesia 
have  occurred  with  minor  operations."     (Hewitt.) 

L.  In  the  operation  for  removal  of  naso-pharyn- 
geal  adenoids,   use   ether,   if   local   anesthesia   is 

unsuitable,  or  if  you  do  not  wish  to  use  bromide 
of  ethyl  anesthesia.  This  operation  is  not  so  very 
painful.  I  have  frequently  seen  Prof.  Coulter  per- 
form it  without  previously  anesthetizing  the  parts 
or  the  patient,  and  it  did  not  seem  to  provoke  very 
great  suffering.     I  have  myself  oj)erated  on  mild 


*  '  NATURE   OF   OPERATION.  39 

cases  without  an  anesthetic.  Hinckel  has  collected 
eighteen  cases  of  death  under  chloroform  in 
this  operation  as  occurring  within  the  last  five 
years.  During  this  same  period,  there  was  only 
one  case  of  death  from  ether  administered  for 
throat  operation.  This  operation  was  a  tonsiloto- 
my.  Dr.  Paltauf  says:  "As  a  result  of  enlargement 
of  the  thymus  gland,  and  other  lymphoid  struc- 
tures, there  is  a  particular  predisposition  of  the 
individual  to  cardiac  syncope."  Syncope  is  a  com- 
mon mode  of  death  under  chloroform  anesthesia. 
Brickner  says:  "In  anesthetizing  patients  of  the 
lymphatic  temperament,  or  in  whom  lymphatic 
enlargements  or  adenoid  vegetations  exist,  choloro- 
form  should  be  rigidly  interdicted."  The  posture 
usually  given  to  the  patient  in  this  operation,  a* 
sitting  or  semi-recumbent  one,  renders  the  use  of 
chloroform  inadmissible.  For  the  removal  of  naso- 
pharyngeal adenoids.  Coulter,  Hawley  and  many 
other  laryngologists  make  use  of  bromide  of  ethyl 
anesthesia. 

M.  In  rectal  surgery  give  ether.  Allingham 
believes  ether  to  be  the  safer  anesthetic  in  rectal 
surgery.  Deep  narcosis  is  here  required.  The  rec- 
tal reflex  is  a  late  reflex  to  depart.  Deep  ether  nar- 
cosis is  less  dangerous  than  deep  chloroform 
narcosis.  The  anal  reflex  is  one  of  the  last  reflexes 
to  be  abolished.  Its  abolition  requires  profound 
anesthesia.    When  this  reflex  is  absent,  no  resist- 


30  GENERAL    AND    LOCAL    ANESTHESIA. 

ance  is  offered  to  finger  or  instrument  entering  tlie 
rectum. 

POSTUEE   OF   PATIEI^T. 

Chloroform  is  the  safest  anesthetic  for  laparot- 
omy in  Trendelenburg's  posture.  (Garrigues, 
Cleveland,  Goodell,  Sutton.)  This  position  tends 
to  produce  congestion  of  brain.  Ether  has  this 
same  property.  Both  causes  combined  may  cause 
rupture  of  cerebral  vessels. 

Any  operation  that  must  be  performed  in  the 
upright,  sitting  or  semirecumbent  posture,  forbids 
the  use  of  chloroform  anesthesia.  As  to  the  knee- 
chest  posture,  it  is  not  a  position  for  anesthesia. 

In  the  prone  posture,  give  ether.  In  this  posi- 
tion the  face,  the  eyeballs,  the  pupils  are  more  or 
less  concealed  from  observation,  the  pulse  is  not  as 
easily  watched  as  in  the  dorsal  position,  therefore 
the  respirations  are  our  main  guide  as  to  the  con- 
dition of  the  patient.  The  breathing  under  ether 
is  strong  and  audible,  hence  the  value  of  ether 
when  this  posture  must  be  maintained  during  the 
course  of  the  operation. 

If  in  a  previous  anesthesia,  the  patient  has  taken 
ether  very  poorly,  the  selection  of  chloroform  is 
proper.  The  same  also  applies  to  chloroform. 
When  in  the  course  of  chloroform  anesthesia,  such 
evidences  of  chloroform  intoxication  as  blanching 
of  face,  great  rapidity  of  pulse  (120-140),  sudden 
dilatation  of  the  pupils,  become  apparent,  if  the 


•  '  PREPARATION   OF   PATIENT.  31 

anesthesia  is  to  be  continued,  yon  will  continne  it 
with  the  nse  of  ether. 

If  the  anesthetist  is  inexperienced,  ether  is  the 
anesthetic  to  be  chosen.  The  safety  margin  is 
mnch  less  with  chloroform  than  with  ether.  Ether 
kills  slowly,  gives  plenty  of  warning.  Chloroform 
gives  no  warning  whatever,  and  kills  quickly. 

Use  chloroform  in  emergency  cases,  where  great 
speed  is  required. 

PEEPAEATION"  OF  PATIENT. 

Prepare  the  patient  carefully;  the  minutest  de- 
tails to  secure  the  best  conditions  should  never  be 
regarded  as  too  insignificant. 

1.  Ascertain  condition  of  heart,  lungs  and  kid- 
neys of  patient.  It  will  guide  you  in  your  selection 
of  the  anesthetic  agent.  Knowing  the  physical 
condition  of  your  patient,  you  will  be  on  the  alert 
for  possible  accidents,  and  be  better  prepared  to 
meet  them.  By  carefully  preparing  your  patient 
for  the  ordeal  of  anesthesia,  you  greatly  minimize 
the  dangers  incident  to  this  condition.  "It  is  far 
better  to  err  on  the  side  of  an  unnecessarily  cau- 
tious investigation  than  to  overlook  symptoms 
which  if  recognized  would  be  of  service  in  conduct- 
ing the  administration  of  the  anesthetic."  (Wm. 
S.  Deutsch.)  An  existing  bronchitis  should  be 
palliated  or  cured.  If  the  operation  is  one  of  a 
certain  duration,  and  the  examination  of  the  urine 
reveals  the  presence  of  albumin  and  casts,  place 


32  GENERAL    AND    LOCAL    ANESTHESIA. 

patient  on  a  milk  diet  for  a  few  days  previoTis  to 
the  operation.  Especially  is  this  indicated  if  the 
daily  passage  of  urine  is  much  below  the  normal. 
In  this  connection  remember  that  water  is  our  best 
diuretic. 

2.  Toilet  of  naso-pharyngeal  passages.  Cleans- 
ing of  naso-pharyngeal  mucosa  by  the  use  of  an 
alkaline  solution.  This  removes  the  secretions, 
thereby  permitting  much  easier  breathing  and  in- 
creasing the  facility  with  which  anesthesia  can  be 
induced  and  maintained.  Ether  promotes  separa- 
tion of  foreign  substances  from  naso-pharynx.  The 
aspiration  of  these  irritating  morbid  products  (des- 
sicated  secretions),  with  their  lurking  micro-organ- 
isms, from  the  higher  to  the  lower  respiratory 
passages,  can  set  up  bronchial  or  pulmonary  in- 
flammation. An  existing  rhinitis  should  be  pal- 
liated or  cured.  If  a  nasal  obstruction  to  free 
breathing  exists,  it  must  be  attended  to. 

3.  Mouth  wash  of  some  efficient  and  pleasant 
antiseptic  solution,  as  listerine  or  borolyptol. 

4.  Examine  the  eyes.  If  patient  has  a  glass  eye, 
remember  it.  Note  the  degree  of  dilatation,  the 
regularity  and  the  mobility  of  the  pupils. 

5.  Examine  joints  for  ankylosis.  ^^An  anky- 
losed  elbow  not  previously  noticed  may  lead  you 
to  believe  the  patient  is  not  relaxed,  and  in  your 
endeavor  to  secure  complete  muscular  relaxation 
the  anesthesia  will  be  pushed  too  far." 


^PREPARATION   OF  TATIENT.  33 

6.  Order  a  hot  bath,  when  practicable,  on  the 
day  before  the  operation.  It  assists  the  emnnctory 
function  of  the  skin. 

7.  Bowels  should  be  evacuated  on  the  night  be- 
fore operation  by  a  laxative.  An  enema  should  be 
given  on  the  morning,  two  hours  before  the  opera- 
tion. This  measure  lessens  the  nausea  and  vomit- 
ing. (Buxton.)  Empty  the  bowels  of  feces,  thereby 
minimizing  fermentation  and  abdominal  distention 
and  avoiding  distressing  pressure  on  the  heart  and 
lungs.  (Gallant.)  "In  my  experience,  the  salmes 
act  best  for  this  purpose,  and  if  the  liver  is  inactive 
may  be  preceded  by  small  doses  of  calomel.  The 
salines,  particularly  the  magnesium  sulphate,  act 
quickly,  clear  out  the  intestinal  tract  thoroughly, 
and  leave  the  secretions  in  a  healthy  condition. 
The  vegetable  cathartics  cause  more  or  less  violent 
and  irregular  peristalsis,  which  keeps  the  patient 
awake,  and  they  usually  leave  the  intestinal  tract 
in  an  irritable  condition.  I  have  frequently  recog- 
nized in  the  dark  vomited  material  following  an 
afternoon  operation,  the  compound  liquorice  pow- 
der taken  the  night  before,  and  have  observed  that 
patients  who  had  taken  a  saline  did  not  vomit  to 
the  same  extent  and  suffered  very  little  from  in- 
testinal disturbances  afterward."   (H.  W.  Carter.) 

8.  On  the  night  before  the  operation,  give  pa- 
tient a  hypnotic,  so  as  to  secure  a  restful  night. 
"A  good  night^s  rest  is  one  of  the  best  means  of 


34  GENERAL    AND    LOCAL    ANESTHESIA. 

fortifying  a  patient    against    subsequent    shock." 
(Gallant.) 

9.  Patient^s  urine  to  be  voided  on  morning  of 
tlie  operation.  In  abdominal  operations  tlie  pa- 
tient is  to  be  catlieterized  before  beginning  tlie 
administration  of  tlie  anesthetic.  A  distended 
bladder  interferes  with  operative  procedures. 

10.  In  women,  hair  should  be  tied  in  towel  or 
cap. 

11.  All  unnecessary  clothing  is  to  be  removed 
and  all  head  jewelry,  such  as  earrings,  combs,  etc. 

12.  In  cases  of  intestinal  obstruction  attended 
with  fecal  vomiting,  as  strangulated  hernia,  etc., 
lavage  of  stomach  before  administering  the  anes- 
thetic lessens  the  danger  of  emesis  during  the 
course  of  the  operation.  The  entrance  of  fecal 
vomit  into  the  trachea  causes  either  pneumonia  or 
death. 

13.  The  best  time  for  an  operation  of  election 
is  early  in  the  morning  or  early  in  the  afternoon. 
These  are  the  periods  of  greatest  vitality.  Late  in 
the  day,  the  body  is  fatigued,  ^individuals  are 
more  liable  to  after-effects  of  an  unpleasant  char- 
acter when  their  bodily  condition  is  one  of  nervous 
exhaustion  and  lowered  vitality."  (Willard  and 
Adler.) 

14.  If  the  operation  is  to  be  performed  in  the 
forenoon  the  patient  should  have  a  light  supper  on 
the  day  previous  to  the  operation,  and  no  breakfast 


RULES  FOR  BOTH  ETHER  AND  CHLOROFORM.      35 

on  the  day  of  the  operation.  If  the  operation  is  to 
be  performed  in  the  afternoon  the  patient  should 
have  a  light  breakfast  and  no  dinner  on  the  day  of 
the  operation. 

15.  If  the  patient  is  very  weak,  for  a  few  days 
previous  to  the  operation  he  should  be  put  upon 
tonic  medication. 

KULES  FOR  BOTH  ETHEE  AND  CHLOEOEOEM. 

1.  The  temperature  of  the  room  in  which  ether 
or  chloroform  are  to  be  used  should  not  be  beloAV 
70  deg.  F.;  when  the  trachea  or  abdomen  are  to 
be  opened  not  below  85  deg.  F.  Eoom  should  be 
free  from  draughts  to  avoid  chilling  of  the  body. 

2.  The  anesthetist  should  be  provided  with  a 
clean  apron  and  clean  towels;  pledgets  of  gauze 
(plain);  Allis  inhaler;  Esmarch  inhaler;  two 
long  artery  forceps,  to  serve  as  gauze-sponge  hold- 
ers; mouth-gag;  tongue  forceps;  hypodermic 
syringes — one  with  strych.  sulph.,  gr.  1-20,  the 
other  with  tr.  digitalis,  m  x-xx;  cosmoline  or  other 
bland  fatty  substance;  rubber  catheters;  tracheal 
canula.  Strychnine,  digitalis  and  ammonia  are  the 
most  serviceable  drugs  in  the  accidents  of  anes- 
thesia. Mtrite  of  amyl,  caffeine  and  atropine  are 
of  little  or  no  use  in  chloroform  poisoning.  (H.  C. 
Wood.)  Restorative  agents  should  be  close  at  hand, 
so  that  in  case  of  impending  danger  relief  can  be 
immediate. 


36  GENERAL    AND    LOCAL    ANESTHESIA. 

3.  Anesthetics  must  not  be  self -administered. 
Up  to  1880,  there  were  20  deaths  on  record  from 
the  self-administration  of  chloroform.     (Lyman.) 

4.  Before  beginning  to  give  the  anesthetic, 
scrnb  yonr  hands  with  soap  and  water  and  put  on  a 
clean  apron.  It  is  cleanly.  It  makes  a  good  im- 
pression. 

5.  Always  clean  cone  or  mask,  sterilization  is 
preferable,  before  each  anesthesia.  This  will  pro- 
mote the  comfort  of  patient,  cleanliness  and  non- 
conveyance  of  infection. 

6.  Always  satisfy  yonrself  of  the  purity  of  the 
drug  that  you  are  going  to  administer.  Enydahl 
attributes  his  great  success  with  anesthesia  to  the 
absolute  purity  of  the  ether  which  he  uses.  "Im- 
pure chloroform  is  very  dangerous  to  life."  (Hare.) 
Perrin  cites  fatalities  due  to  impure  chloroform. 
The  impurities  of  chloroform,  such  as  chlorine  and 
hydrochloric  acid,  lengthen  and  intensify  the  stage 
of  excitement,  aggravate  the  irritating  action  of 
chloroform  upon  mucoiis  membranes,  and  increase 
the  liability  to  sickness  during  and  after  anes- 
thesia. They  are  said  to  favor  the  production  of 
cardiac  and  respiratory  syncope.  Tasse  says,  "Im- 
pure chloroform  is  capable  of  poisoning  the  nerv- 
ous system,  producing  paralysis,  and  transient  or 
permanent  albuminuria."  The  purity  of  ether 
may  be  tested  by  adding  to  it  a  small  amount  of  oil 
of  copaiba.    Clearness  of  solution  indicates  purity 


RULES  FOR  BOTH  ETHER  AND  CHLOROFORM,      37 

of  ether;  any  cloudiness  or  emulsion  indicates  im- 
purities. Ether  readily  develops  impurities.  It 
should  not  be  exposed  to  light.  The  can  should  be 
kept  closed.  To  ascertain  the  purity  of  chloroform, 
dip  chemically  pure  filter  paper  into  chloroform, 
and  allow  the  latter  to  evaporate.  Pure  chloro- 
form leaves  no  odor.  If  the  chloroform  tested  is 
impure,  a  more  or  less  irritating^  unpleasant  smell 
remains.  Chloroform  should  be  kept  in  glass- 
stoppered,  dark-colored  bottles.  The  addition  to 
chloroform  of  a  small  quantity  of  ethylic  alcohol 
1-1000,  prevents  its  decomposition. 

7.  Win  the  patients'  confidence,  reassure  them 
as  to  the  outcome  of  the  operation;  tell  them  that 
there  is  no  cause  for  alarm,  that  anesthesia  has 
no  dangers.  The  heart  can  be  made  functionally 
incompetent  by  fright.  "The  element  of  fear  can 
easily  lead  to  heart  failure."  (Eichardson.)  A  fatal 
result  taking  place  within  a  few  minutes  after  the 
commencement  of  the  inhalation  of  the  anesthetic 
can  be  caused  by  syncope,  the  effect  of  fear.  Anx- 
iety and  fear  are  heart  depressants,  and  may  pro- 
duce dangerous,  and  even  fatal,  symptoms.  Ex- 
amples: Desault  was  about  to  perform  a  lithotomy; 
to  demonstrate  the  line  of  incision,  he  drew  his 
finger-nail  over  the  patient's  perineum.  The  pa- 
tient uttered  a  loud  cry  and  suddenly  died.  Caze- 
nave  was  about  to  operate  on  a  very  nervous 
patient.    He  did  not  give  chloroform,  but  made  a 


38 


GENERAL    AND    LOCAL    ANESTHESIA. 


pretense  by  putting  a  towel  over  patient's  nose. 
The  respiration  and  heart  stopped.  The  patient 
was  dead. 

8.  Always  give  the  anesthetic  npon  an  empty 
stomach.  The  patient  should  not,  however,  be 
kept  too  long  without  food.  If  the  patient  is 
too  long  without  food,  bile  is  apt  to  flow  into  the 
stomach  and  induce  vomiting  during  anesthesia. 
Five  to  six  hours  should  have  elapsed  since  food 
was  last  taken.  By  taking  this  precaution  the 
tendency  to  vomiting  is  lessened.  "Vomiting  is 
almost  a  constant  sequel  in  those  who  have  inhaled 
the  drug  upon  a  full  stomach.''  (Hare.)  A  dis- 
tended stomach  impedes  the  heart's  action.  In 
operations  upon  the  stomach  or  intestines.  Dr.  Mc- 
Burney  washes  out  stomach  previous  to  anesthe- 
tizing patient.  Vomiting  is  annoying  to  the  anes- 
thetist; it  retards  the  production  of  anesthesia; 
it  can  produce  harm  by  disturbing  the  relation  of 
wound  flaps,  by  giving  rise  to  hemorrhage  from  cut 
vessels  imperfectly  blocked,  by  disturbing  and  soil- 
ing dressings.  In  abdominal  operations,  it  causes 
a  protrusion  of  intestines;  aspiration  of  vomited 
matter  can  cause:  aspiration  pneumonia  and  as- 
phyxia; vomited  matter  may  lodge  in  the  esopha- 
gus, and  from  there  compress  trachea  and  cause 
asphyxia. 

9.  The  anesthetist  should  be  behind  the  pa- 
tient's head,  or  at  side  of  head.    He  should  have  a 


RULES  FOR  BOTH  ETHER  AND  CHLOROFORM.      89 

knowledge  of  the  different  steps  of  the  operation 
that  is  to  be  performed  and  of  the  length  of  time 
that  will  be  required  to  perform  it.  For  example, 
in  an  operation  on  hemorrhoids  while  the  sphinc- 
ter is  being  dilated  the  anesthetist  should  remove 
the  cone  or  mask  from  the  patient's  face.  Stretch- 
ing of  the  sphincter  excites  deep  inspiration  and  if 
the  cone  is  not  removed  the  patient  may  inhale  an 
overdose  of  the  anesthetic.  In  an  operation  on  a 
cleft  palate  he  must  know  when  to  intermit  and 
when  to  resume  the  administration  of  the  anes- 
thetic. Previous  to  the  cutting  of  important 
nerves  by  the  operator  he  must  be  sure  that  his 
anesthesia  is  complete. 

10.  Always,  when  the  nature  of  the  operation 
allows  it  (and  there  are  very  few  operations  that  do 
not),  anesthetize  the  patient  in  the  recumbent  pos- 
ture. The  giving  of  chloroform  to  a  patient  in  the 
sitting  posture  is  an  unjustifiable  error.  The  Hy- 
derabad commission  insists  that  chloroform  be 
given  in  the  recumbent  position.  The  recumbent 
posture  is  to  be  selected  because  it  facilitates  the 
circulation  between  the  heart  and  the  brain, 
thereby  lessening  the  tendency  to  syncope.  Fail- 
ure of  respiration  in  chloroform  narcosis  is  due  to 
anemia  of  the  respiratory  center.  The  horizontal 
posture  does  not  favor  this  anemia;  the  sitting 
posture  does.  This  position  is  also  the  position 
of  election  for  ether  anesthesia.     ^^Dentists  who 


40  GENERAL    AND    LOCAL    ANESTHESLA.. 

administer  ether  to  their  patients  in  an  erect  pos- 
ture have  more  deaths  during  anesthesia,  propor- 
tionately, than  surgeons  who  administer  to  pa- 
tients in  the  recumbent  posture."    (Hare.) 

Force  of  gravity  has  a  marked  influence  upon 
the  circulation.  The  sitting  and  vertical  postures 
cause  a  fall  of  blood  pressure  in  the  carotid  arter- 
ies, the  horizontal  posture  restores  the  blood-pres- 
sure in  these  vessels  to  its  normal  state.  Chloro- 
form lowers  the  blood  pressure  by  its  depressing 
action  on  the  vaso-motor  apparatus,  and  on  the 
heart  and  its  contained  ganglia.  The  upright,  sit- 
ting and  semirecumbent  postures  lower  the  blood 
pressure  in  the  cranial  and  cervical  vessels.  Chlo- 
roform and  faulty  position  acting  together  produce 
an  anaemia  of  the  medulla  oblongata.  From  this 
anaemia,  if  it  be  sufficiently  marked,  results  syn- 
cope. 

The  splanchnic  vaso-motor  mechanism  controls 
the  abdominal  vascular  area.  Chloroform  para- 
lyzes this  mechanism.  This  paralysis  allows  dila- 
tation of  the  abdominal  veins,  and  in  the  sitting 
and  similar  postures,  the  force  of  gravity  aiding, 
the  blood  drains  into  these  veins,  the  right  heart  is 
emptied  and  the  cerebral  circulation  fails. 

It  is  the  most  convenient  position  for  the  anes- 
thetist. It  gives  him  a  better  view  of  the  face,  of 
the  pupils,  of  the  respiratory  movements  of  the 
patient  and  enables  him  to  easily  palpate  the  facial 


"  '     RULES  FOR  BOTH  ETHER  AND  CHLOROFORM.      41 

or  temporal  artery.  These  arteries  keep  him  in- 
formed of  the  patient's  heart  action.  In  this  posi- 
tion he  can  easily  prevent  tongue  from  falling 
backward  by  pressing  and  keeping  forward,  with 
little  and  ring  finger,  the  rami  of  the  jaw.  He  can 
easily  feel  the  expiratory  current  of  air,  by  putting 
thumb  occasionally  over  the  patient's  month, 
thereby  ascertaining  that  the  patient  is  breathing. 
This  is  important  because  the  epigastric  region 
may  rise  and  fall,  and  still  no  air  enter  the  lungs. 
He  can  easily  hear  the  respiratory  murmur.  He 
can  better  watch  action  of  the  diaphragm. 

The  position  admits  of  better  expansion  of  chest. 
For  the  safe  administration  of  chloroform  and 
ether,  expiration  must  not  be  impeded.  This  con- 
dition is  only  obtained  in  positions  that  permit  the 
lungs  to  expand  and  contract  freely.  To  secure 
this  full  expansion  and  contraction  of  the  lungs, 
in  addition  to  suitable  position,  the  air  passages 
must  be  straightened  out,  the  glottis  must  be  free, 
and  the  tongue  prevented  from  falling  back.  The 
side  position  impedes  respiration,  and  especially  is 
this  marked  when  a  pleural  effusion  is  present. 
When  the  heart's  action  is  interfered  with,  by  old 
adhesions,  by  tumors,  etc.,  the  side  position  greatly 
increases  the  tendency  to  heart-failure  or  syncope. 

The  prone  position  hampers  respiration,  (a)  by 
preventing  free  expansion  of  chest,  (b)  by  prevent- 
ing descent  of  diaphragm,  owing  to  the  pressure 


43  GENERAL    AND    LOCAL    ANESTHESIA. 

exerted  in  this  position  on  abdominal  wall  and  vis- 
cera. "Knee-chest  posture  must  never  be  used  in 
anesthesia/^  (Hewitt.)  In  obstetrics,  semi-lateral 
position  can  be  used.  "It  is  said  that  during 
gynecological  and  obstetric  operations,  in  which 
the  patients  are  kept  lying  on  the  left  side,  the 
pulse  and  respiration  have  been  more  satisfactory 
during  anesthesia  from  chloroform  than  when  pa- 
tients have  taken  it  in  the  dorsal  position.  It  may 
be  that  the  view  which  attributes  special  safety  to 
the  drug  in  obstetrical  cases  took  its  origin  in  the 
fact  that  the  customary  obstetrical  position  in 
England  and  in  this  country  is  upon  the  left  side. 
Buxton  thinks  that  the  influence  of  position  is 
unquestionably  important,  and  is  due  to  the  fact 
that  the  condition  of  the  heart,  lungs,  tongue  and 
larynx  is  more  nearly  correct  physically  and  phy- 
siologically when  the  patient  is  placed  in  the  left 
lateral  position  instead  of  on  the  back/^  (Am. 
Text-Book  of  Surgery.) 

In  laryngeal  and  abdominal  operations  the  Tren- 
delenburg position  is  very  satisfactory.  The 
anesthesia,  however,  must  be  started  in  recumbent 
posture,  and  when  patient  is  under  the  anesthetic, 
position  is  changed.  If  in  the  Trendelenburg  po- 
sition, the  cyanosis  of  face  becomes  marked,  patient 
must  temporarily  be  returned  to  horizontal  posi- 
tion. 

In  operations  upon  naso-pharyngeal  adenoids,  if 


PRECAUTIONS  TO  BE  OBSERVED.  43 

the  operator  insists  upon  sitting  posture,  begin 
administering  the  anesthetic  in  the  recumbent 
position,  then,  once  patient  is  anesthetized,  slowly 
raise  him  to  sitting  posture  and  have  head  and 
shoulders  well  thrown  forward.  (Hewitt.)  This 
position  is  favorable  for  the  escape  of  blood.  Never 
use  chloroform  in  this  position.  Henry  Davis,  in 
the  British  Med.  Journal,  for  the  removal  of  naso- 
pharyngeal adenoids,  advises  having  patient  on 
back,  with  head  drawn  over  the  table,  as  in  the 
method  now  so  frequently  employed  for  staphylor- 
rhaphy. He  says  that  in  this  position  blood  can- 
not trickle  downward  in  the  larynx,  but  that  it  col- 
lects in  the  roof  of  the  pharnyx,  which  in  this  posi- 
tion forms,  as  it  were,  a  cup  from  which  the  blood 
and  fragments  of  adenoid  tissue  can  be  easily  re- 
moved. 

PKECAUTIONS    BEFORE    AND    DUEING   ANESTHESIA. 

11.  In  operations  upon  throat,  elevate  shoulders 
and  keep  head  pendent  so  that  blood  will  not 
gravitate  into  the  trachea. 

12.  Always  have  patient's  mouth  free  from  false 
teeth,  chewing  gum,  or  other  foreign  bodies,  before 
starting  to  administer  the  anesthetic.  Foreign 
bodies  interfere  with  respiration.  If  an  emergency 
arises  demanding  the  rhythmic  traction  of  the 
tongue,  they  are  in  the  way.  They  may  slip  into 
the  trachea,  and  cause  pneumonia  or  asphyxia. 
Case  243.     L3rman's  collection:     "A  patient  was 


44  GENERAL    AND    LOCAL    ANESTHESIA. 

passing  into  stage  of  insensibility,  hex  respiration 
became  laborious,  her  countenance  livid,  her  pulse 
weak,  and  all  symptoms  of  suffocation  appeared. 
She  coughed  up  some  bloody  mucus  and  died. 
The  tongue  was  pulled  forward  and  with  the  finger 
a  metallic  plate  of  artificial  teeth  was  drawn  out  of 
pharnyx.  Death  from  suffocation."  In  children, 
look  for  loose  temporary  teeth,  so  as  to  be  on 
guard,  in  case  the  use  of  the  tongue  forceps  be- 
comes necessary.  Rough  handling  can  dislodge  a 
tooth,  and  its  intrusion  into  the  trachea  can  cause 
suffocation. 

13.  Always  see  that  all  articles  of  dress  are  loos- 
ened and  that  there  are  no  constrictions  about 
waist  or  neck.  Such  constrictions  impede  the 
circulation  and  the  respiratory  movements.  The 
Hyderabad  Commission  found  that  tight  lacing 
greatly  increased  the  risks  of  chloroform  admin- 
istration, on  account  of  the  imperfect  respiration 
and  the  consequent  tendency  to  asphyxia  to  which 
it  gave  rise. 

14.  Always  smear  nose,  chin  and  lips  with  vase- 
line or  cold  cream,  or  oil,  or  glycerine.  Use  a 
piece  of  clean  gauze  and  not  your  finger.  Ether 
and  chloroform  irritate  the  skin  and  the  mucous 
membranes.  By  taking  this  precaution  the  patient 
is  protected  from  an  annoying  postoperative  ery- 
thema or  dermatitis.  "Applied  to  the  skin,  chloro- 
form is  a  powerful  irritant,  and  if  the  contact  be 


•  .'•  PRECAUTIONS  TO  BE  OBSERVED.  45 

prolonged  and  evaporation  be  prevented,  vesication 
will  ensue/^    (Willard  and  Adler.) 

15.  Always  cover  the  eyes  of  the  patient  with  a 
folded  towel  or  piece  of  ganze.  This  is  to  prevent 
the  irritation  of  the  conjunctiva  that  follows  its 
exposure  to  the  fumes  of  ether  or  chloroform.  It 
also  protects  the  eyes  from  any  ether  or  chloro- 
form that  might  accidentally  be  spilled  on  the  face. 
Once  complete  anesthesia  has  been  induced,  this 
can  be  removed  so  as  to  enable  you  to  watch  the 
pupils.  Be  careful  not  to  pour  any  of  the  chloro- 
form or  of  the  ether  in  the  patient^s  mouth. 

16.  Keep  the  patient's  arms  to  side  of  body,  and 
feel  pulse  at  facial  or  temporal  arteries.  Arms 
must  not  be  pinned  over  patient's  chest.  A  good 
way  is  to  flex  forearm  on  arm  and  then  pin  lower 
part  of  sleeve  of  forearm  to  upper  part  of  sleeve  of 
arm.  See  that  arms  do  not  hang  over  sharp  edges 
of  operating  table.  See  that  they  do  not  lie 
between  the  border  of  the  operating  table  and  the 
body  of  the  operator  or  any  of  his  assistants.  Do 
not  place  the  patient's  arm  under  his  head  and  do 
not  bring  it  in  that  position  so  as  to  palpate  the 
radial  pulse.  The  facial  and  temporal  arteries  give 
you  equally  good  information  and  do  not  expose 
your  patient  to  postanesthetic  paralysis.  For  the 
same  reason  do  not  allow  the  patient's  legs  to  hang 
over  the  edge  of  the  table. 

Among  the   reported   cases    of    postanesthesia 


46  GENERAL    AND    LOCAL    ANESTHESIA. 

paralysis,  some  have  been  due  to  compression, 
others  to  traction  of  brachial  plexus  or  some  of  its 
branches  by  the  arm  having  been  pulled  over  head 
of  patient.  Others  have  been  due  to  the  arm  hav- 
ing been  caught  as  in  a  wedge  between  the  operator 
and  the  operating  table.  The  elevation  of  the  arms 
lessens  the  costo-clavicnlar  interspace,  and  thus 
can  cause  compression  of  the  brachial  plexus  or  of 
some  of  its  branches.  In  the  vast  majority  of  cases 
postanesthesia  paralysis  is  due  to  a  lesion  of  the 
nerve-trunks.  It  is  a  "peripheral  paralysis.'^  It  is 
always  (excluding  the  very  rare  cases  in  which  it 
may  be  due  to  the  rupture  of  a  cerebral  vessel  dur- 
ing the  stage  of  excitement)  due  to  direct  or  indi- 
rect pressure  upon  a  nerve  or  nerves  during  the 
administration  of  an  anesthetic.  When  due  to  this 
cause,  it  is  preventable  in  every  instance.  Though 
the  upper  extremities  are  most  commonly  affected, 
it  may  also  involve  the  lower  extremities.  Some 
cases  of  postanesthesia  paralysis  have  been  caused 
by  the  elbows  of  the  anesthetist  resting  heavily 
upon  the  clavicular  region  of  the  patient  and  press- 
ing upon  the  brachial  plexus.    (Leszinsky.) 

17.  Let  there  be  no  unnecessary  exposure  of  the 
patient^s  body  to  cold.  Anesthetics  tend  to  reduce 
the  temperature;  hence,  in  administering  them, 
rational  measures  should  be  adopted  to  prevent  loss 
of  heat.  Maintain  the  patient^s  body-temperature 
before,  during  and  after  the  operation.    Have  his 


PRECAUTIONS  TO  BE  OBSERVED.  4? 

bed  warmed  by  hot  bricks  and  hot-water  bottles. 
See  that  he  does  not  lie  in  a  puddle  of  cold  water 
during  the  course  of  anesthesia.  Object:  To  pre- 
vent chilling  of  body  and  consequent  bronchitis 
and  pneumonia.  In  discussing  after-ether  pneu- 
monia, Buxton  says:  "That  removal  of  the  patient 
to  a  cold  ward  after  he  has  been  in  a  warm  operat- 
ing room  and  subjected  to  severe  surgical  shock, 
has  been  the  true  cause  of  the  lung  trouble  in  many 
cases.^^  Chilling  of  the  surface  of  the  body  pro- 
duces congestion  of  the  internal  organs.  Hypere- 
mia of  an  organ  predisposes  it  to  inflammation.  If 
to  the  hyperemic  condition  of  the  renal  and  pul- 
monary parenchyma  is  added  the  irritating  action 
which  attends  the  inhalation  of  ether  and  chloro- 
form (not  as  marked  with  chloroform)  by  the  lung, 
as  well  as  their  elimination  by  the  kidneys  and  the 
lungs,  inflammation  can  easily  be  excited  in  these 
organs.    Prevention  is  more  certain  than  cure. 

18.  Eemember  that  all  methods  that  employ  a 
large  quantity  of  anesthetic  are  faulty.  A  skilled 
anesthetist  will  use  much  less  anesthetic  to  induce 
and  maintain  anesthesia  than  one  who  is  unused 
to  the  administration  of  anesthetics.  "The  amount 
of  the  anesthetic  used,  no  matter  which  one  it  may 
be,  bears  a  direct  proportion  to  the  amount  of 
shock,  exhaustion,  pulmonary  edema,  pneumonia 
or  nephritis  that  develops  after  anesthesia."  (Ben- 
nett.)   Certain  operations  require  that  the  patient 


48  GENERAL    AND    LOCAL   ANESTHESIA. 

should  be  more  deeply  -under  the  influence  of  the 
anesthetic,  and  so  necessitate  an  increase  of  the 
amount  to  be  used.  All  operations  on  the  rectum, 
on  the  urethra  and  the  perineum  are  of  this  kind. 
All  methods  involving  marked  asphyxial  symptoms 
are  subject  to  grave  objections. 

19.  Never  crowd  the  anesthetic.  It  is  the  large 
dose  inhaled  at  once  that  causes  death.  If  the 
operator  asks  of  you  to  push  the  anesthetic,  bear 
in  mind,  that  though  his  time  may  be  very  valua- 
ble, the  patient's  life  is  much  more  so.  During 
my  interneship  at  Cook  County  Hospital  I  wit- 
nessed two  deaths  that  were  caused  by  crowding 
the  anesthetic.  "The  pushing  of  the  anesthetic 
vapor  so  as  to  get  a  rapid  anesthesia  at  all  risks, 
is  as  dangerous  a  plan  as  could  be  possibly  de- 
vised/' (Sir  B.  W.  Eichardson.)  "Hasty  satura- 
tion of  tissues  with  a  powerful  anesthetic  may 
cause  speedy  death."  (Hare.)  Pushing  the  inhal- 
ation of  a  poison  from  the  start  overwhelms  the 
vital  centers,  while  its  slow  administration  habit- 
uates them  to  it. 

20.  Never  give  an  anesthetic  to  a  woman  unless 
a  third  person  be  present.  This  is  suggested  for 
the  comfort  of  the  patient  and  for  your  protection. 
There  are  cases  on  record  where  the  patient  has 
accused  her  medical  attendant  of  assault  while  he 
had  her  under  the  effects  of  the  drug.  These 
accusations  were  brought  forth  either  for  the  pur- 


.'  PRECAUTIONS  TO  BE  OBSERVED.  49 

pose  of  blackmail,  or  because  the  patient  had  expe- 
rienced, during  the  anesthetic  sleep,  an  orgasm  of 
which  the  anesthetizer  appeared  to  be  the  cause. 

21.  In  giving  an  anesthetic  do  not  relax  yonr 
vigilance  from  the  beginning  to  the  end.  Attend 
to  the  anesthetic  and  to  the  anesthetic  only.  Ee- 
niember  that  no  one  guide  can  be  entirely  relied 
upon  to  the  exclusion  of  all  the  others.  All  the 
guides,  such  as  the  condition  of  the  pupils,  the 
nature  of  the  respirations,  the  force  and  frequency 
of  the  pulse,  etc.,  are  of  value  and  must  all  be  taken 
into  consideration  during  the  induction  and  main- 
tenance of  surgical  anesthesia.  Deaths  have  oc- 
curred in  all  stages  of  anesthesia.  Accidents  are 
sudden,  and,  not  to  be  fatal,  must  be  detected  at 
their  inception.  The  anesthetist  should  not  watch 
the  operation.  (Phocas,  le  ISTord  Medical.)  "\¥hile 
it  is  not  necessary  or  safe  for  the  anesthetist  to 
watch  the  operation,  he  should  know  how  it  is 
progressing,  so  as  to  stop  the  anesthetic  when  it  is 
no  longer  required. 

22.  Do  not,  as  a  routine  measure,  complicate 
anesthesia  by  the  use  of  such  agents  as  morphine, 
atropine,  etc.  By  their  action  on  the  respiration, 
on  the  pulse  and  on  the  pupils,  they  mask  the 
patient's  real  condition.  There  are  exceptional  in- 
stances where  these  agents  can  be  properly  used. 
Morphia,  given  previous  to  beginning  the  adminis- 
tration of  the  anesthetic,  increases  the  liability  to 


50  GENERAL    AND    LOCAL    ANESTHESIA. 

vomiting  during  anesthesia.  Analysis  of  15,000 
anesthesias  collected  by  the  Society  of  Scandina- 
vian Surgeons  (March  1,  1894,  March  1,  1895) 
showed  that  vomiting  occurred  in  ether  anesthesia 
without  injection  of  morphine  in  14  per  cent;  with 
morphine,  in  25  per  cent.  Chloroform,  without 
injection  of  morphine,  in  lO-J  per  cent;  with  mor- 
phine, in  14  8-10  per  cent.  Morphine  is  a  respira- 
tory depressant.  Morphine  interferes  with  the 
motility  of  the  iris.  Those  agents,  such  as  mor- 
phine and  atropine,  interfere  with  means  employed 
for  resuscitation  if  the  patient  gets  into  a  danger- 
ous condition.  For  instance,  the  effects  of  mor- 
phia would  last  longer  than  the  effects  of  the  anes- 
thetic, and  the  morphia  could  not  be  counteracted 
by  any  other  drugs  than  those  that  would  be  em- 
ployed to  resuscitate  the  patient  from  the  anesthe- 
sia-narcosis. 

23.  During  anesthesia,  from  time  to  time,  turn 
patient's  head  to  either  side  so  as  to  allow  the 
escape  of  loosened  secretions  from  mouth  and  nose. 
Kotation  of  head  on  trunk  has  little  or  no  influence 
upon  respiration.  This  procedure  facilitates  the 
outflow  of  mucus  and  saliva  from  mouth.  These, 
during  anesthesia,  tend  to  induce  cough,  and  if 
swallowed,  favor  retching  and  vomiting.  Cough- 
ing, retching  and  vomiting,  when  caused  by  swal- 
lowed saliva,  and  mucus,  mislead  us  into  thinking 
that  patient  is  recovering  consciousness^  and  incite 


PRECAUTIONS  TO  BE  OBSERVED.  51 

US  to  give  him  more  of  tlie  anesthetic  than  he 
needs.  Patients  who  during  anesthesia  swallow 
much  mucus  are  much  more  liable  to  be  sick  after- 
wards. "Swallowing  of  much  mucus  excites  post- 
anesthetic vomiting/^     (Blumfeld.) 

24.  Should  the  patient  to  be  anesthetized  suffer 
from  partial  or  complete  nasal  obstruction,  place  a 
small  gag  between  his  teeth  before  commencing 
the  administration  of  the  anesthetic.  Partial 
nasal  occlusion  is  liable  to  become  complete  dur- 
ing anesthesia,  by  reason  of  the  increased  vascu- 
larity of  the  parts.  In  all  operations  about  mouth, 
pharynx  and  lower  jaw,  it  is  a  good  rule  to  intro- 
duce gag,  at  an  early  period  during  the  induction 
of  anesthesia.  When  the  tongue  is  the  seat  of  the 
growth,  pass  a  thread  through  its  tip  before  mus- 
cular relaxation  sets  in.  This  thread  will  give  you 
a  better  control  of  tongue.  Should  the  tongue 
fall  backward,  thereby  mechanically  preventing 
the  entrance  of  air  into  the  lungs,  by  pulling 
thread  you  can  easily  pull  tongue  forward.  In 
operations  about  face,  Souchon's  apparatus  is  very 
serviceable. 

25.  Sudden  change  from  recumbent  to  vertical 
posture  during  anesthesia  must  be  avoided.  Dan- 
ger of  syncope.  It  is  always  far  more  convenient 
for  the  anesthetist,  and  it  is  also  safer  for  the 
patient,  if  he  be  anesthetized  upon  the  operating- 
table.    "The  extent  to  which  a  patient  has  to  be 


52  GENERAL    AND    LOCAL    ANESTHESIA. 

moved  about  while  under  an  anesthetic  affects  his 
liability  to  after-sickness/^    (Bliimf eld.) 

26.  Eoom,  in  which  the  anesthetic  is  adminis- 
tered, must  be  quiet.  Conversations  and  noises 
excite  the  j)atient's  attention  and  retard  the  pro- 
duction of  anesthesia.  If  there  is  a  burning  gas- 
jet  in  the  room,  see  that  ventilation  is  assured. 
Chloroform,  in  being  decomposed  by  the  gas-flame, 
liberates  free  chlorine.  This  gas  is  a  respiratory 
irritant,  and  can  cause  bronchial  irritation  in  oper- 
ator and  assistants,  and  asphyxia  in  patient.  If 
chloroform  is  to  be  administered  in  a  room  lighted 
by  gas-light  it  is  imperative  that  free  ventilation 
be  secured.  Patient  must  not  be  anesthetized 
beneath  a  gas-flame.  "Chloroform,  if  given,  in  an 
unventilated  room  near  a  gas-flame,  excites  in  the 
attendants  present  in  the  room  a  choking  and 
stinging  sensation  in  the  throat  and  chest,  result- 
ing in  incessant  coughing."  (Winslow.)  These 
symptoms  of  bronchial  and  laryngeal  irritation, 
such  as  a  constant,  dry,  spasmodic  and  paroxysmal 
cough,  and  a  feeling  of  distress  and  oppression  over 
the  chest,  are  provoked  chiefly  by  hydrochloric  and 
chlorine  gas  (Hare),  these  substances  being 
resultants  of  the  changes  which  chloroform  vapor 
undergoes  in  the  presence  of  gas,  oil  or  other  flame, 
chlorine  gas  being  the  main  toxic  agent  responsi- 
ble for  the  occurrence  of  the  accidents.  The  fore- 
mentioned  symptoms,  to  which  can  be  added  a 


PRECAUTIONS  TO  BE  OBSERVED.  53 

stinging  sensation  in  the  nostrils,  the  perception 
of  a  pungent  odor,  etc.,  are  chiefly  experienced  by 
the  anesthetist.  They  may,  however,  affect  the 
patient  as  well  as  bystanders.  It  is  not  rare  for 
chemists  working  in  small  rooms  with  chloroform 
and  lighted  Bunsen  lamps  to  suddenly  become 
attacked  with  severe  coughing.  Dr.  Mey,  West- 
phalia, reports  an  operation  for  gun-shot  wound  of 
the  abdomen  lasting  four  hours  under  the  influence 
of  chloroform,  and  in  the  presence  of  gas-light, 
during  which  the  surgeons  and  sisters  in  attend- 
ance were  overcome  by  the  decomposition  products 
of  the  anesthetic,  one  sister  dying  on  the  second 
day  following  the  operation.  Emil  Aronson  re- 
ports a  case  in  which  the  patient  and  the  attend- 
ing physician  were  killed  by  these  decomposition 
products. 

27.  Have  patient's  head  on  level  with  body. 
"Keep  patient's  head  in  extension,  but  not  dropped 
backward  over  end  of  table."  (Hare.)  Flexion  of 
head  on  neck  lessens  the  caliber  of  air  way  and 
favors  stertor  and  respiratory  embarrassment. 
"Extension  and  projection  forward  and  backward, 
both  pull  epiglottis  away  from  glottic  opening,  but 
in  the  latter  posture  the  soft  palate  is  strapped 
over  dorsum  of  tongue  and  the  patient  is  forced  to 
breathe  through  his  nose,  which  is  often  partly  or 
entirely  occluded  by  mucus,  by  hypertrophies, 
whereas,  when  the  head  is  extended  and  projected 


54  GENERAL    AND    LOCAL    ANESTHESIA. 

forward,  the  patient  can  readily  breathe  through, 
both  mouth  and  nasal  chambers/^  (Hare.)  If 
patient  insists  upon  having  pillow  below  head,  re- 
move it  as  soon  as  he  is  asleep. 

28.  Keep  jaw  forward  and  upward.  Falling 
down  of  jaw  is  attended  by  falling  backward  of 
the  tongue.  The  tongue,  in  falling  back,  carries 
with  it  the  epiglottis,  and  this,  by  falling  back^  pre- 
vents entrance  of  air  into  lungs. 

29.  Operators  must  minimize  the  duration  of 
operations  to  time  consistent  with  their  proper  and 
thorough  execution,  because  the  longer  the  oper- 
ation the  more  anesthetic  is  required.  Anesthetics 
are  dangerous  per  se.  Chloroform  is  a  virulent 
protoplasmic  poison.  Ether  produces  a  marked 
diminution  in  the  amount  of  hemoglobin.  The 
shorter  the  anesthesia,  the  less  liability  there  is 
to  after-vomiting  and  other  disagreeable  after- 
effects. The  danger  of  death  is  present  as  long  as 
the  anesthesia  continues.  In  this  connection  it 
must  be  said  that  the  surgeon  must  avoid  undue 
delay  before  commencing  the  operation.  Opera- 
tion should  be  begun  as  soon  as  the  patient  is 
completely  anesthetized. 

30.  Warn  the  patient,  especially  if  he  be  an 
adult,  that  at  first  a  sensation  of  choking  will  be 
experienced,  but  that  it  will  soon  pass  off.  When 
that  feeling  of  suffocation  comes  he  will  feel  less 


PRECAUTIONS  TO  BE  OBSERVED. 


55 


alarmed^  knowing  that  he  is  experiencing  the  ex- 
pected.   Tell  patient  that  he  must  not  straggle. 

31.  Patient's  struggles  should  be  quietly  but 
resolutely  restrained.  When  a  patient  struggles 
he  holds  his  breath.  This  is  disadvantageous,  be- 
cause any  obstruction  to  breathing  is  very  likely  to 
impede  the  heart's  action.  If  breath  is  held  for 
any  length  of  time,  pulmonary  circulation  and 
right  side  of  heart  become  engorged.  With  ether 
the  cause  of  struggling  is  generally  too  strong  a 
vapor  being  administered  from  the  commence- 
ment. Give  patient  a  breath  or  two  of  fresh  air. 
During  struggling,  pushing  of  ether  is  dangerous. 

32.  Struggling  in  chloroform  or  ether  anesthe- 
sia may  be  due  to  fright,  which  may  lead  to  resis- 
tance; avoid  fright  by  calming  patient's  fears. 
Choking  or  asphyxia  is  generally  due  to  the  cap 
being  held  too  close  to  patient's  face  and  to  non- 
sufficient  admixture  of  fresh  air  with  the  anes- 
thetic; avoid  it  by  holding  mask  not  too  close  to 
patient's  face  at  beginning  of  anesthesia;  give 
patient  a  breath  or  two  of  fresh  air  to  relieve  symp- 
toms. It  is  also  due  to  an  overdose  of  chloroform 
or  ether.  Permit  a  breath  or  two  of  air.  If 
patient  struggles  violently,  and  the  breathing  be- 
comes abnormally  deep,  give  patient  fresh  air  and 
do  not  reapply  cap  till  the  breathing  becomes 
normal  again. 


56  GENERAL  AND  LOCAL  ANESTHESIA. 

To  summarize,  the  objections  to  struggling  are 
based  on  the  facts  that  it  interferes  with  the  cir- 
culation and  nndnlv  taxes  the  heart,  and  that  it 
fixes  the  thorax  and  embarrasses  and  often  renders 
respiration  impossible. 

33.  Encourage  patient  to  take    deep    breaths. 
They  help  to  overcome  the  sensation  of  suffoca- 
tion.   He  must  also  be  told  not  to  hold  his  breath. 
By  holding  his  breath  he  debilitates  his  respira- 
tory center,  owing  to  lack  of  oxygen  furnished  to 
it.     Then  when  the  necessity  of  breathing  over- 
comes all  other  impulses,  a  gasping  inspiration  is 
taken,  the  center  is  flooded  with  the  anesthetic 
agent,  and  death  may  supervene;  this  is  especially 
liable  to  occur  with  chloroform.     "Deaths  which 
take  place    comparatively    early    in    chloroform 
anesthesia  are  due  primarily  to    rigidity,    strug- 
gling and  holding  of  breath."     (Hill,  Barnard.) 
H  patient  complains  of  suffocation,  and  struggles 
or  breathes  irregularly,  remove  mask  and  allow  a 
few  breaths  of  fresh  air.     Prof.    Jno.  Ashhurst 
recommends  the  following  procedure:     "Eequest 
patient  to  blow  out.    The  vapor  of  ether  is  so  irri- 
tating to  the  throat  that  it  is  very  difficult  to  vol- 
untarily draw  it  by  deep  inhalation,  but  it  is  per- 
fectly easy  to  blow  into  the  cone,  and  as  a  full 
expiration  is  inevitably  followed  by  a  deep  inspira- 
tion, the  surgeon^s  purpose  is  most  readily  accom- 
plished;   contrary  to    what    happens    when    the 


PRECAUTIONS  TO   BE  OBSERVED.  57 

patient  is  directed,  as  is  usually  the  case,  to  draw 
in  his  breath." 

34.  Encourage  patient  to  expectorate  mucus, 
and  during  the  anesthesia,  if  mucus  accumulates 
in  pharynx,  remove  it  with  gauze  sponges  held  by 
long  artery  forceps.  Facilitate  its  outflow  from 
mouth  by  turning  head  to  one  side.  Mucus, 
mechanically,  obstructs  the  entrance  of  air  into  the 
lungs.  The  swallowing  of  mucus  causes  retching 
and  vomiting,  both  during  and  after  the  adminis- 
tration of  the  anesthetic.  If  mucus  trickles  down 
into  the  stomach  during  the  operation^  the  patient 
is  almost  certain  to  vomit,  and  in  most  cases  the 
vomited  material  consists  of  mucus  with  some  gas- 
tric juice  and  bile. 

35.  Should  the  patient  begin  to  vomit  during  the 
course  of  the  anesthesia,  immediately  turn  his  head 
to  one  side  and  catch  vomitus  in  towel  or  basin. 
By  the  aid  of  this  measure  the  vomited  matter  will 
be  ejected  from  the  mouth,  instead  of  being  sucked 
into  the  larynx.  Neglect  of  this  precaution  has 
been  followed  by  fatalities.  These  have,  prin- 
cipally, occurred  in  cases  of  fecal  vomiting  due  to 
intestinal  obstruction.  It  is  the  anesthetist^s  duty 
to  see  that  the  vomited  matter  is  removed  from  the 
pharynx.  Swab  out  pharynx  with  a  gauze  sponge 
held  by  long  forceps.  "During  anesthesia,  if  vom- 
ited food  has  entered  the  larynx  and  is  not  ejected 
by  coughing,  it  is  necessary  to  promptly  perform 


58  GENERAL    AND    LOCAL    ANESTHESIA. 

tracheotomy  and  hold  the  tracheal  wound  open  or 
introduce  a  tube^  and  practice  artificial  respira- 
tion." (Wharton.)  If  patient  has  vomited  in  mask 
or  cone,  discard  it  and  take  a  clean  one. 

36.  Eemember  that  in  cases  where  there  has 
been  a  severe  hemorrhage,  the  amount  of  anes- 
thetic necessary  to  maintain  safe  anesthesia  is 
small. 

37.  Should  tongue  fall  backward  and  embarrass 
breathing,  it  is  rare  that  one  needs  the  aid  of  a 
tongue  forceps  to  bring  it  forward.  Tongue-for- 
ceps often  lacerate  tongue,  and  the  lesions  which 
they  inflict  cause  suffering  for  a  few  days.  Use 
the  following  method  to  bring  tongue  forward.  I 
have  often  used  it,  and  it  has  never  disappointed 
me:  With  fingers  (ring  and  little  finger)  push 
forwards  and  upwards  angles  of  lower  jaw;  by  this 
procedure  the  condyles  of  lower  jaw  are  thrown,  so 
to  speak,  on  the  eminentia  articularis.  This  move- 
ment will  invariably  bring  forward  the  tongue. 

INCOMPLETE    ANESTHESIA. 

38.  Under  no  circumstances  should  incomplete 
anesthesia  be  deemed  sufiicient  for  even  the  most 
trivial  operation.  See  that  anesthesia  is  complete 
before  the  operation  is  begun.  If  the  operator  be- 
gins operating  before  the  anesthesia  is  complete, 
it  becomes  harder  and  requires  more  anesthetic 
than  would  otherwise  be  required  to  obtain  com- 
plete surgical  anesthesia.    The  patient  being  sub- 


INCOMPLETE  ANESTHESIA.  59 

jected  to  traumatic  irritation,  such  as  cutting  and 
pulling  of  nerves,  the  anesthetics  act  more  slowly. 
Another,  and  still  more  valid  objection  to  operat- 
ing under  incomplete  anesthesia,  is  that  pain  may 
inhibit  the  heart's  action.  Therefore  see  that  there 
is  complete  muscular  relaxation,  abolition  of  the 
ciliary,  masseter,  palpebral  and  buccal  reflexes,  and 
contraction  of  the  pupils  (the  latter  is  not  required 
in  ether  narcosis,  but  is  indispensable  in  chloro- 
form narcosis)  before  an  incision  is  made.  The 
conjunctival  reflex,  when  abolished,  does  not 
always  indicate  a  corresponding  abolition  of  reflex 
action  generally.  I  quote  from  Brunton:  "Sud- 
den stoppage  of  heart  is  usually  ascribed  to  chloro- 
form, and,  no  doubt,  concentrated  chloroform 
vapor  inhaled  into  the  lungs  may  arrest  the  heart. 
Very  commonly,  though,  it  is  reflex,  and  when 
death  occurs  in  such  a  case  it  is  due  to  the  want 
of  chloroform,  and  not  to  its  excess.  In  the  great 
majority  of  cases  recorded,  as  deaths  from  chloro- 
form, the  statement  is  made  that  the  quantity  used 
was  very  small  and  the  anesthesia  incomplete; 
that  these  operations,  though  trivial,  were  danger- 
ous under  imperfect  anesthesia  and  not  at  all  dan- 
gerous when  either  no  anesthesia  was  used  or 
when  narcosis  was  complete.  The  reason  for  this 
is  probably  that  when  no  anesthetic  was  given 
irritation  of  sensory  nerves  during  operation 
caused  two  effects — slowing  or  stoppage  of  heart 


60  GENERAL    AND    LOCAL    ANESTHESIA. 

and  reflex  contraction  of  vessels.  This  contrac- 
tion of  vessels  neutralizes  cardiac  weakness,  main- 
tains blood  pressure  and  thus  prevents  syncope. 
During  imperfect  chloroform  anesthesia,  the  reflex 
effect  on  the  heart  persists,  so  that  irritation  of  a 
sensory  nerve  may  produce  syncope  by  stopping 
the  supply  of  arterial  blood  from  the  heart.  In  its 
weakened  state  it  will  not  pump  enough  into  the 
arteries^  while  the  blood  still  flows  rapidly  into  the 
dilated  capillaries  and  veins/^  As  Hare  says,  "The 
man  is  suddenly  bled  into  his  own  vessels  as 
effectively  as  into  a  bowl."  It  is  perfectly  possible 
for  a  patient  to  bleed  to  death  in  his  own  arteries. 
"Danger  of  partial  anesthesia  lies  particularly  in 
not  keeping  reflex  action  in  abeyance.  It  is  essen- 
tial that  both  sensation  and  reflex  action  be  abol- 
ished." (A.  E.  Edwards.)  Imperfect  anesthesia 
renders  patient  peculiarly  liable  to  cardiac  failure 
through  afference  of  sensory  impressions  conveyed 
from  cutaneous  or  visceral  nerves. 

39.  If  operator  notices  that  the  patient's  blood 
is  becoming  dark,  he  should  tell  the  anesthetist. 
The  patient  is  not  inhaling  enough  oxygen,  is 
getting  an  overdose  of  the  anesthetic  or  the 
respiration  is  obstructed.  Withdraw  the  cap  and 
remove  any  impediment  to  the  respiration  that 
may  be  present.  This  impediment  may  be  an 
excessive  amount  of  mucus  in  the  throat;    may 


RESPIRATION   OF  THE   PATIENT.  61 

be  a  faulty  position  of  the  tongue;  may  be  a  for- 
eign body  in  the  larynx,  pharynx  or  trachea. 

EESPIKATION   OF   THE   PATIENT. 

40.  See  that  operator's  arms,  or  those  of  his 
assistant,  do  not  rest  on  chest  or  abdomen  of 
patient.  All  things  that  embarrass  the  respiratory 
movements  of  the  patient  must  be  avoided.  In 
pelvic,  perineal  and  rectal  operations,  bear  in  mind 
that  all  leg  supports  which  pass  around  the  neck 
and  shoulder  of  the  patient  embarrass  respiration 
and  may  by  compressing  branches  of  the  brachial 
plexus  cause  paralysis.  The  best  supporters  are 
those  which  are  attached  to  the  table. 

Watch  the  rate,  the  depth,  the  audibility  of  the 
breathing  and  the  degree  of  stertor.  ^'Through- 
out  chloroformization,  the  respirations  must  be 
constantly  watched."  (Buxton.)  The  respirations 
must  be  regular,  deep  and  of  normal  frequency. 
Throughout  the  inhalation  of  the  anesthetic  the 
breathing  must  be  free  and  not  impeded  in  any 
way.  The  respirations  are  watched  in  ether  and 
chloroform  anesthesia,  because  (a)  the  character 
of  the  respirations  gives  us  information  as  to  the 
depth  of  anesthesia,  (b)  The  rapidity  and  the 
depth  of  breathing  govern  the  amount  of  the  drug 
inhaled.  An  amount  of  anesthetic  which  can  be 
given  with  safety  during  easy  breathing  may  kill, 
if  given,  during  exaggerated  respiration.  For  ex- 
ample, a  given  quantity  of  chloroform  or  ether  will 


32  GENERAL    AND    LOCAL    ANESTHESIA. 

exert  its  greatest  effect  when  the  respiration  is 
deep  and  quick^  because  the  vapor  is  then  carried, 
in  a  given  period  of  time,  in  larger  qiiantity,  into 
the  air-spaces  of  the  lungs.  The  respirations  of  the 
etherized  patient  are  nsnally  deeper,  quicker  and 
noisier  than  those  of  the  chloroformed  patient. 

Movement  of  the  chest  wall,  or  of  the  diaphragm, 
is  not  sufficient  evidence  that  the  respiratory 
function  is  being  carried  on  properly.  The  sounds 
of  respiration  must  be  heard,  the  breath  must  be 
felt.  If  costal  respiration  becomes  feeble,  or  is 
replaced  by  purely  diaphragmatical  breathing, 
death  will  speedily  follow  if  artificial  breathing  be 
not  immediately  resorted  to.  The  value  of  arti- 
ficial breathing  lies  in  its  property  of  furnishing 
oxygen  to  the  blood,  of  clearing  the  iungs  of  anes- 
thetic vapors  and  of  helping  on  the  circulation  of 
the  blood. 

Marked  quickening  of  respiration  means  an 
overdose  of  the  anesthetic,  unless  it  is  accounted 
for  by  reflex  action^  such  as  stretching  of  the 
sphincter  ani  and  working  with  the  mucosa  of  the 
rectum,  or  by  some  mechanical  interference  with 
the  breathing^  as  the  presence  of  mucus  in  the  air- 
passages.  Snoring  and  stertorous  breathing  are 
evidences  of  profound  narcosis.  Deep,  stertorous 
breathing  is  usually  due  to  paralysis  of  the  faucial 
and  pharyngeal  muscles.  Stertor  may  depend  upon 
the  presence  of  mucus  in  the  throat.    Eemove  it. 


'     •  '  RESPIRATION   OF   THE   PATIENT.  63 

with  gauze  sponges  held  by  long  artery  forceps. 
During  the  course  of  anesthesia,  at  times,  turn  the 
patient's  head  to  one  or  the  other  side  so  as  to 
allow  the  saliva  and  mucus  to  run  out  at  the  side 
of  the  mouth.    With  ether,  snoring  and  stertorous 
breathing  are  not  necessarily  dangerous.    To  pre- 
vent pharyngeal  stertor,  head  must  be  in  such  a 
position  as  will  not  bend  the  neck  too  far  back  or 
approximate  the  jaw  too  near  the  sternum.   Turn- 
ing the  head  to  one  side  will  often  give  relief. 
Elevation  of  the  jaw  frequently  stops  the  stertorous 
character  of  the  breathing.    In  fleshy  individuals, 
and  in  patients  suffering  from  nasal  obstruction,  as 
hypertrophied  tonsils,  naso-pharyngeal  adenoids, 
etc.,  snoring  and  stertorous  breathing  will  persist 
during  entire  anesthesia.  When  breathing  becomes 
stertorous,  if  chloroform  is  the  anesthetic  you  are 
using^  cease  administration.    Then  watch  for  some 
slight  indication  of  returning  reflex  action,  as  a 
dilating  and  active  pupil,  etc.     Then  give  chloro- 
form and  reinduce  stertor.     If  ether  is  the  anes- 
thetic agent  used,  continue  its  administration,  but 
in  doses  just  sufficient  to  maintain  the  anesthesia. 
If  respiration  is  embarrassed,  see  that  no  ob- 
struction to  the  entrance  of  air  into  the  lungs  is 
present,  as  regards  improper  position  of  head;  for- 
eign body  in  mouth,  pharynx  or  larynx;  falling 
backward  of  tongue  and  with  it  of  the  epiglottis; 
accumulation   of  saliva   and  mucus  in  pharynx. 


64  GENERAL    AND     LOCAL    ANESTHESIA. 

See  that  patient  gets  more  fresh  air.  In  the  stage  oi 
excitement,  breathing  is  labored.  In  the  stage 
of  surgical  anesthesia  it  becomes  regular  as  soon 
as  the  muscles  are  completely  relaxed.  The  slow- 
ing of  the  respiration  is  due  to  the  depressing 
action  of  the  anesthetic  on  the  pneumo-gastric 
nerve.  In  the  stage  of  paralysis  or  collapse,  the 
respirations  are  slow,  sighing,  shallow  and  finally 
cease. 

There  are  certain  reflexes  present  during  full 
surgical  anesthesia,  such  as  those  excited  by  dilat- 
ing the  sphincter  ani,  by  the  rough  handling  of  the 
peritoneum,  especially  the  breaking  down  of  peri- 
toneal adhesions,  by  the  compression  or  rough 
handling  of  the  ovaries  or  testes.  These  reflexes 
manifest  themselves  by  an  increase  in  the  rate  and 
in  the  depth  of  the  respiration.  During  their 
occurrence  the  amount  of  chloroform  or  ether, 
being  inhaled,  should  be  temporarily  diminished; 
as  the  increased  frequency  and  increased  depth  of 
respiration  would,  were  this  precaution  not  taken, 
lead  to  the  inhaling  of  an  overdose,  and  to  conse- 
quent ill  effects. 

Grive  chloroform  drop  by  drop;  you  thereby  give 
it  in  its  most  diluted  form  with  air,  and  lessen  the 
liability  of  any  reflex  action  on  the  vagus.  An 
unduly  strong  dose  of  chloroform  can  cause  closure 
of  the  glottis.  Sudden  arrest  of  the  heart  or  of  the 
respiration  in  the  initial  stage  of  chloroform  nar- 


RESPIRATION    OF    THE    PATIENT. 


65 


cosis  has  been,  experimentally,  proved  by  Europ- 
pean  observers  to  be  often  due  to  reflex  action 
from  the  filaments  of  the  trigeminus  in  the 
Schneiderian  membrane  to  the  vagus.  The  pos- 
sibility of  this  reflex  action  is  mnch  lessened  by 
giving  the  chloroform  in  diluted  form,  and  increas- 
ing the  strength  of  the  vapor  very  gradnally.  To 
counteract  this  reflex  action,  some  surgeons  spray 
patient's  nasal  chambers  with  a  weak  cocaine  solu- 
tion previous  to  beginning  the  administration  of 
the  anesthetic. 

The  direct  cause  of  primary  arrest  of  respiration 
v/hen  ether  is  given  is  one  of  the  following  factors : 

a.  Irritation  of  peripheral  filaments  of  the  tri- 
facial, which  reflexly  causes  spasm  of  the  glottis. 
(Kretzschmar.)  This  is  avoided  by  giving  vapor  in 
diluted  form  to  begin  with.  If,  despite  this  pre- 
caution, it  occurs,  continuing  the  administration 
of  the  anesthetic  will  benumb  the  peripheral  fila- 
ments of  trifacial,  and  in  that  way  cause  relaxation 
of  the  glottis. 

b.  Irritation  of  the  peripheral  vagi  in  the  lungs. 
This  inhibits  respiratory  movements,  and  momen- 
tarily impedes  the  action  of  the  heart.  Here  the 
pushing  of  the  anesthetic  benumbs  the  peripheral 
ends  of  the  vagi  in  lungs  and  thus  puts  a  stop  to 
the  irritation. 

c.  Spasm  of  muscular  fibers  of  smaller  bronchial 
tubes  induced  by  the  irritant  vapor  of  ether.  Con- 


66  GENERAL    AND    LOCAL    ANESTHESIA. 

tinue  to  administer  the  anesthetic,  and  the  mns- 
cular  fibers  of  the  bronchial  tubes  will  soon  relax, 
and  breathing  will  take  place.  By  gradually  giving 
the  anesthetic,  that  is,  gradually  increasing  the 
strength  of  the  vapor,  the  feeling  of  suffocation 
and  spasm  of  glottis  are  rarely  produced,  and  ster- 
torous breathing  and  lividity  of  face  are  not  fre- 
quently seen.  In  the  respiratory  forgetfulness 
which,  at  times,  occurs  at  the  beginning  of  ether 
anesthesia,  pour  some  ether  on  patient^s  abdomen. 
The  sensation  of  cold  which  attends  the  evapora- 
tion of  this  substance  will  reflexly  excite  respira- 
tion. 

CONDITION   OF   THE   CIKCULATOKY  SYSTEM   DURING 
ANESTHESIA. 

41.  The  condition  of  the  circulation  during 
anesthesia.  Before  beginning  to  administer  the 
anesthetic,  locate  the  facial  or  temporal  artery. 
During  the  course  of  anesthesia,  these  arteries  are 
to  keep  you  informed  of  the  strength  and  of  the 
rate  of  the  heart's  action.  A  weak  heart,  a  weak 
pulse;  a  labored  heart,  a  thready  pulse.  The  color 
of  the  face,  lips  and  ears  will  also  give  you  infor- 
mation as  to  the  heart's  condition.  It  shows  the 
activity  of  the  capillary  circulation.  The  fall  of 
blood  pressure,  which  is  the  normal  condition  of 
anesthesia  with  chloroform,  is  due  to  the  action  of 
chloroform  on  the  vasomotor  center  in  the  medulla 
oblongata.     During  the  stage  of  excitement  the 


CONDITION    OF    THE    CIRCULATORY    SYSTEM.  67 

pulse  is  accelerated;  a  frequency  of  144  pulsations 
to  the  minute  has  been  reported.  Usually  the 
more  marked  the  excitement,  the  greater  the  fre- 
quency of  the  pulse. 

In  the  stage  of  surgical  anesthesia,  the  pulse 
loses  in  frequency,  and  acquires  fullness  and  com,- 
pressibility.  If  the  administration  is  now  con- 
tinued with  care,  the  pulse  will  not  lose  these 
qualities  during  the  entire  duration  of  the  anes- 
thesia. In  the  stage  of  paralysis  the  pulse  is  rapid, 
feeble,  fluttering,  finally  ceasing  or  stopping  sud- 
denly without  warning.  When  the  pulse  becomes 
rapid,  130  to  160  in  children,  120  to  140  in  adults, 
resort  to  stimulation;  use  strychnine  sulph.  gr. 
1-20;  use  tr.  digitalis,  m.  xv.  to  xxv.  It  is  needless 
to  say  that  during  anesthesia  these  agents  must 
always  be  given  hypodermically.  If  the  pulse 
seems  feeble,  slow,  irregular,  intermittent,  the 
anesthetic  must  be  withdrawn  and  fresh  air  freely 
admitted  till  improvement  occurs.  Respiration 
and  circulation  may  cease  simultaneously  on  sec- 
tion of  a  nerve. 

There  is  an  increased  frequency  of  the  pulse, 
when,  though  the  thorax  is  rising  and  falling  regu- 
larly, no  air  is  entering  the  lungs;  when  patient 
is  about  to  vomit  (pulse  also  becomes  irregular 
previous  to  vomiting);  after  considerable  loss  of 
blood;  during  stage  of  excitement;  during  man- 
ipulation of  a  considerable  portion  of  the  intes- 


68  GENERAL    AND    LOCAL    ANESTHESIA. 

tines;  during  dilation  of  anal  sphincter;  during 
operations  in  cervical  regions,  when  cardiac  accel- 
erating branches  of  pneumogastric  may  be  irri- 
tated; at  the  beginning  of  anesthesia  pulse  may  be 
rapid  from  fear. 

There  is  a  decreased  frequency  of  the  pulse  in 
cranial  operations;  in  operations  in  the  cervical 
regions;  when  cardiac  inhibitory  branches  of 
pneumogastric  nerve  may  be  irritated;  in  case  of 
pressure  or  traction  on  the  diaphragm;  during 
gastric  operations. 

Sudden  stoppage  may  appear,  momentarily, 
from  any  of  the  following  causes: 

(a)  Severing  a  nerve  in  amputation. 

(b)  Sudden  escape  of  the  contents  of  a  cystic 
tumor. 

(c)  Upon  removal  of  a  large  abdominal  tumor. 
(In  frogs,  exposure  and  irritation  of  the  intestines 
will  stop  the  heart.) 

(d)  Pressure  on  testicle  or  spermatic  cord,  dur- 
ing hernial  operation. 

(e)  Ligation  of  an  ovarian  pedicle. 

(f)  Spasmodic  contraction  of  diaphragm  pre- 
ceding vomiting. 

(g)  Dilatation  of  anal  sphincter. 

42.  Condition  of  the  muscular  system  during 
anesthesia.  Muscular  movements  during  stage 
of  excitement  are  violent,  purposeless  and  most 
always  independent  of  the  will.     The  voluntary 


CONDITION    OF    THE   MUSCULAR    SYSTEM.  69 

muscles  are  the  first  to  be  influenced  by  anesthetics. 
It  is  important  to  note  that  the  involuntary  mus- 
cles are,  so  to  speak,  refractory  to  the  influence  of 
anesthetics.  It  is  rare  for  patients  during  anesthe- 
sia to  pass  urine  or  to  void  feces. 

The  usefulness  of  obstetrical  anesthesia  is  based 
upon  this  nonpredisposition  of  the  involuntary 
muscles  to  the  action  of  anesthetics. 

In  the  period  of  rigidity  which  precedes  that  of 
relaxation,  if  the  breathing  stops  for  more  than  a 
moment,  practice  artificial  respiration. 

Anesthesia  is  not  complete  before  complete 
muscular  relaxation  has  set  in.  Perfect  relaxation 
of  limbs  is  an  indication  that  the  patient  is  ready 
for  the  operation.  During  the  stage  of  excitement, 
the  patient  struggles  because  he  believes  himself 
asphyxiated.  The  jaws  are  more  or  less  fixed.  Ex- 
citement and  struggling  gradually  subside.  Buc- 
cal paralysis  accompanying  respiration  indicates 
that  patient  is  going  under.  A  little  later,  snoring 
and  stertorous  breathing  indicate  faucial  and 
pharyngeal  paralysis  and  that  the  stage  of  surgical 
anesthesia  has  been  reached. 

In  the  stage  of  surgical  anesthesia  the  muscles 
are  relaxed  (if  the  arm  is  raised  it  falls  back  of  its 
own  weight);  jaws  are  relaxed.  If  during  anes- 
thesia, patient  regains  control  of  the  jaw,  he  is 
recovering  consciousness.  In  the  stage  of  paralysis, 
muscles  are  in  the  same  condition  as  in  the  pre- 


70 


GENERAL  AND  LOCAL  ANESTHESIA. 


ceding  stage.  All  patients  in  going  nnder  with 
ether  pass  through  a  stage  in  which  there  is  more 
or  less  rigidity.  Pushing  the  ether  does  not  over- 
come^ but  prolongs,  the  rigidity,  whereas  with- 
drawing the  ether  brings  relaxation  of  muscles 
without  return  to  consciousness. 

COXDITIOX     OF     CEXTKAL     XEEVOUS     SYSTEM. 

43.  Condition  of  Central  ^N'ervous  System:  In 
the  stage  of  excitement,  patient  seems  intoxicated. 
There  is  a  quick  succession  of  ideas,  of  strange 
sensations,  of  hallucinations.  Ideas  become  inco- 
herent. Patient  becomes  drowsy.  Cerebral  torpor 
overtakes  him.  Delirium  may  be  mild,  may  be 
violent.  Excitement  and  delirium  are  due  to 
marked  hyperemia  of  brain.  Excitement  is  most 
marked  in  robust,  strong  people  and  in  alcoholics. 
Sensibility  is  impaired.  Stage  of  surgical  anesthe- 
sia. The  patient  is  calm;  his  brain  anemic;  sen- 
sation is  abolished.  This  is  due  to  suppression  of 
the  function  of  the  sensory  nerves.  State  of  paral- 
ysis same  as  the  preceding.  "Ether,"  says  Hare, 
"depresses  first  the  perceptive  and  intellectual  cere- 
bral centers,  next  the  sensory  side  of  the  spinal 
cord,  then  the  sensory  and  motor  portions  of  the 
medulla  oblongata;  and  with  this  depression,  death 
ensues."  The  motor  centers  of  the  cord  are  affected 
later  than  the  spinal  sensory  centers.  This  applies 
also  to  chloroform,  both  drugs  acting  similarly  on 
the  nervous  system. 


STAGE    OF   EXCITEMENT.  71 

44.  Watcli  carefully  the  color  of  the  face,  lips 
and  lobes  of  ear.  Blanching  of  these  parts  may- 
occur  and  must  never  escape  notice.  It  is  a  sign 
of  impending  danger.  By  pinching  the  ear  and 
watching  how  rapidly  the  capillaries  refill,  and 
noticing  whether  the  ear  returns  to  its  normal 
redness,  you  get  an  idea  of  the  activity  and  of  the 
condition  of  the  circulation.  Cyanosis,  though 
more  marked  in  ether  narcosis,  is  of  less  import- 
ance than  in  chloroform  anesthesia.  If  patient^s 
face  becomes  dusky,  give  him  fresh  air.  In  the 
stage  of  excitement,  follow  patient  in  his  efforts 
to  get  away  from  cone  or  mask  and  keep  it  applied 
to  his  face. 

45.  Stage  of  Excitement:  The  face  is  congested. 
This  congestion  is  due  to  the  turgescence  of  the 
superficial  vessels.  Stage  of  surgical  anesthesia; 
face  resumes  a  more  normal  color,  and  may  become 
covered  with  a  viscous  perspiration.  Stage  of 
paralysis  or  collapse;  face  deeply  cyanosed  and 
veins  distended  or  face  is  suddenly  blanched.  This 
blanched  appearance  indicates  impending  trouble. 
At  slight  indication  of  blanching  of  the  face  re- 
move the  mask,  allow  the  patient  a  few  breaths  of 
fresh  air.  Pallor  indicates  that  circulation  is 
depressed  either  by  surgical  shock,  insufficient 
breathing,  or  an  overdose  of  the  anesthetic.  A 
certain  degree  of  pallor  and  a  slow^  rather  feeble 
pulse   are   not   necessarily   indicative   of   danger. 


72  GENERAL    AND    LOCAL    ANESTHESIA. 

They  often  precede  vomiting^  and,  when  so  caused, 
need  occasion  no  alarm;  they  often  precede  respir- 
atory failure,  and  by  putting  the  anesthetist  on 
his  guard  enable  him  to  avoid  this  serious  con- 
dition. 

Cyanosis  means  embarrassed  respiration.  It 
indicates  that  the  patient  is  not  inhaling  enough 
oxygen,  is  inhaling  too  much  anesthetic.  It  is 
most  often  met  with  in  stout,  short,  thick-necked 
people,  and  necessitates  a  more  careful  adjustment 
of  the  head  and  close  attention  to  the  patient.  It 
may  be  due  to  accumulated  mucus,  to  a  faulty 
position  of  tongue,  to  a  foreign  body  in  the  trachea. 
Eelieye  it  by  removing  the  cause.  A  turgid  con- 
dition of  veins  of  head  and  neck,  associated  with 
a  dusky  color  of  surface,  especially  if  there  be 
muscular  rigidity,  with  a  rapid  and  irregular  pulse 
and  an  excited  state  of  the  respiration,  should 
always  lead  to  a  temporary  suspension  of  the 
inhalations. 

EEFLEX     ACTIOX. 

46.  Coughing  and  swallowing,  in  the  very  early 
stages  of  anesthesia,  point  to  too  strong  a  vapor 
and  should  be  met  by  a  diminution  in  its  strength. 
Should  they  tend  to  arise  after  surgical  anesthesia 
has  become  established,  they  should  be  met  by 
increasing  the  strength  of  the  vapor,  because  they 
then  indicate  that  the  patient  is  recovering  from 
the  eSects  of  the  anesthetic.     The  function  of 


REFLEX   ACTION.  "^S 

deglutition  during  profound  anesthesia  is  sus- 
pended. The  presence  of  the  pharyngeal  reflex 
(the  act  of  deglutition  excited  by  the  presence  of 
the  anesthetic  vapor  or  mucus)  indicates  that  more 
of  the  anesthetic  is  required.  In  the  stage  of 
excitement,  the  cornea  is  sensitive,  reflex  action 
continues,  pu.pil  dilates  and  reacts  to  light. 

Stage  of  Surgical  Anesthesia:  All  the  reflexes 
except  those  of  the  involuntary  muscles  are  abol- 
ished. By  keeping  these  reflexes  barely  abolished, 
a  patient  may  be  kept  in  this  state  for  hours.  The 
abolition  of  reflex  action  denotes  that  the  operation 
can  begin.  By  carefully  watching  the  pharyngeal 
reflex,  and  keeping  it  abolished,  coughing,  retching 
and  vomiting  can,  with  very  few  exceptions,  be 
prevented  during  the  course  of  the  operation. 
This  is  a  fact  of  no  small  importance,  in  abdominal, 
rectal  and  perineal  surgery. 

The  patient  may  cough  at  first;  this  is  due  to 
direct  irritation  by  anesthetic  vapors  of  the  supe- 
rior laryngeal  nerve  filaments.  This  cough  is, 
usually,  slight  and  transitory;  however,  should  it 
persist  and  be  associated  with  dyspnea,  suspend  the 
inhalations  till  quiet  is  restored. 

When  stomachic  disturbance  is  evidenced  by 
the  rapid  dilatation  of  the  pupils,  by  the  spasmodic 
contractions  of  the  diaphragm,  by  short,  convul- 
sive movements  of  the  abdominal  muscles,  by 
rapid,  short,  jerky  respirations,  with  a  pulse  of 


'^4  GENERAL    AND    LOCAL    ANESTHESIA. 

increased  rapidity  and  by  repeated  efforts  at  deglu- 
tition, Tomiting  will  soon  take  place,  in  almost  all 
instances.  Pushing  of  the  anesthetic  if  it  succeeds 
in  abolishing  these  reflexes,  will  prevent  Yomiting. 
As  soon  as  it  is  apparent  that  the  patient  will  cer- 
tainly vomit,  remove  the  mask,  turn  the  head 
quickly  to  one  side,  always  to  the  side  away  from 
the  field  of  operation,  catch  vomit  on  towel,  and 
clean  mouth  and  pharynx.  As  soon  as  vomiting 
has  ceased,  resume  anesthesia. 

Under  ether,  the  pupils  contract  at  first,  and 
then  remain  moderately  dilated  during  surgical 
anesthesia. 

The  observation  of  the  pupil  is  of  great  import- 
ance during  chloroform  anesthesia.  Its  behavior 
while  the  patient  is  under  the  influence  of  this 
anesthetic  furnishes  us  invaluable  information  con- 
cerning the  stage  and  the  depth  of  anesthesia,  and 
the  condition  of  the  patient. 

The  third  nerve  center  which  governs  the  pupil, 
unlike  the  respiratory  center,  is  not  a  vital'  center. 
In  the  stage  of  excitement,  the  corneal  reflex  is 
present,  and  the  pupil  is  dilated  and  reacts.  When 
the  patient  is  going  under  or  coming  around,  the 
dilatation  and  the  activity  of  the  pupil  that  are 
present  are  thus  explained.  The  dilatation  occurs 
because  mental,  sensory  and  sympathetic  impulses 
affect  the  half  narcotized  cerebrum  and  cause  reflex 
inhibition  of  the  third  nerve  center.    The  activity 


,     -  STATE   OF   SURGICAL    ANESTHESIA.  75 

of  pupil  is  due  to  the  fact  that  the  center  itself  has 
not  been  reached  by  the  anesthetic.  A  similar  dila- 
tation of  pupil  is  produced,  under  ordinary  circum- 
stances, by  fright,  pain  or  a  blow  on  the  abdomen. 

As  long  as  the  pupil  dilates  in  response  to 
sensory  stimuli,  such  as  the  pinching  of  the  skin, 
etc.,  anesthesia  is  not  sufficiently  deep  to  allow  the 
commencement  of  the  operation.  Vomiting  causes 
dilatation  of  pupil  similar  to  that  which  occurs 
when  patient  emerges  from  the  anesthetic  state. 

State  of  Surgical  Anesthesia:  Corneal  reflex 
is  abolished;  pupil  is  contracted;  myosis.  A 
contracted  pupil  is  a  sign  of  complete  and  safe 
narcosis.  We  must  endeavor  to  keep  the  pupil 
contracted.  Operator  may  now  begin.  This  con- 
traction of  the  pupil  occurs  because  all  the  cerebral 
reflexes  are  barred  and  the  third  nerve  center  is 
consequently  unimpeded.  The  center  of  the  third 
nerve  is  now  only  inhibited  by  the  light  reflex. 
The  same  condition  occurs  in  deep  sleep. 

Stage  of  Paralysis  or  Collapse:  Corneal  reflex 
is  always  abolished.  The  Narcotic  has  reached  the 
nerve  center  and  gradually  overwhelmed  it;  conse- 
quently nerve  control  has  ceased.  The  pupil  dilates 
widely  and  the  light  reflex  is  abolished.  Withdraw 
chloroform  till  contraction  of  pupil  occurs  as  a 
result  of  the  recovery  of  the  third  nerve  center. 
Dilated  and  fixed  pupil  denotes  danger  of  immi- 
nent syncope  of  respiratory  center.     Eespiratory 


76  GENERAL    AND    LOCAL   ANESTHESIA. 

syncope  is  the  most  common  cause  of  deatli  from 
chloroform  anesthesia.  Use  restorative  measures. 
'Tailnre  of  the  pupils  to  respond  to  light,  or  their 
wide  dilatation  is  a  sign  of  approaching  danger. 
The  inhalation  should  be  at  once  discontinued,  the 
head  lowered,  the  tongue  drawn  well  out  of  the 
mouth,  the  heart  stimulated,  and  artificial  respira- 
tion begun.'^     (Am.  Text-Book  of  Surgery.) 

During  the  course  of  the  anesthesia,  the  pupil 
may  dilate  gradually,  may  dilate  suddenly.  The 
gradual  dilatation  of  the  pupil  denotes  that  patient 
is  recovering  from  the  anesthetic.  Resume  the 
administration  of  the  chloroform  and  continue  it 
drop  by  drop  until  the  pupils  again  become  myotic. 
Then  suspend  the  administration.  In  a  few 
moments,  when  the  pupils  again  show  a  tendency 
to  dilate  gradually,  administer  some  more  chloro- 
form, and  keep  on  in  this  way,  always  maintaining 
the  pupils  contracted.  The  sudden  dilation  of  the 
pupils  denotes  that  the  third  nerve  center  has  been 
overwhelmed  by  the  anesthetic.  It  is  a  serious  con- 
dition. It  must  at  all  hazards  be  avoided.  This 
sudden  relaxation  of  the  iris,  under  chloroform, 
is  a  part  of  the  relaxation  of  death.  Upon  its 
occurrence,  immediately  cease  the  administration 
of  the  chloroform,  invert  the  patient,  practice  arti- 
ficial respiration,  and  resort  to  stimulation.  The 
first  three  measures  are  by  far  the  most  valuable. 

When  with  symptoms  of  asphyxia,  pupil  is  con- 


POINTS    CONCERNING   CHLOROFORM.  77 

tracted  and  remains  contracted  (it  suddenly  dilates 
in  this  condition  when  canse  being  uncounteracted 
verges  on  a  fatal  result)^  the  asphyxia  is  due  to 
some  mechanical  obstruction  to  breathing  and  not 
to  an  overdose  of  chloroform.  This  condition  can 
easily  be  remedied,  and  should  never  prove  fatal. 

Per  contra,  if  the  chloroform  be  present  in  an 
overdose,  the  pupils  are  always  dilated.  The 
dilating  and  active  pupil  of  the  stage  of  excitement 
and  of  insufficient  narcosis  can  be  distinguished 
from  the  dilated  pupil  of  deep  narcosis  or  collapse 
by  the  greater  freedom  of  the  light  reflex,  by  the 
supervention  of  other  reflexes,  such  as  cough, 
vomiting,  irregular  breathing  and  by  the  absence 
of  the  glassy  fixation  of  the  eyes  so  characteristic 
of  profound  narcosis. 

47.  During  the  course  of  anesthesia,  do  not 
stimulate  your  patient  with  hypodermics  of  strych- 
nia, sulphate,  nitroglycerine,  etc.,  unless  it  is 
absolutely  necessary.  Do  not  get  needlessly 
alarmed.  Do  not  annoy  the  operator  with  un- 
founded fears.  Most  always  alarming  symptoms 
disappear  by  just  permitting  the  patient  to  come 
a  little  from  under  the  anesthetic. 

A    FEW    POINTS    CONCERNING    CHLOEOFORM    ANES- 
THESIA. 

1.  Always  reduce  to  the  minimum  consistent 
with  full  and  complete  anesthesia,  the  amount  of 
chloroform  vapor  inhaled.     This  also  applies  to 


78  GENERAL    AND     LOCAL    ANESTHESIA. 

ether.  Usually  the  more  of  the  anesthetic  absorbedj 
the  longer  is  the  interval  before  consciousness 
returns.  It  is  impossible  to  find  a  dosage  that  will 
do  for  all  patients.  The  individual  must  be 
studied,  and  the  only  person  that  can  do  this  is 
the  educated  anesthetizer.  "Patients  vary  as  to 
the  quantit}^  of  the  anesthetic  needed  and  time 
consumed  in  anesthetizaiion.  This  depends  upon 
the  method  of  anesthetization  and  the  type  of 
patient.  In  general,  it  may  be  said,  males  require 
more  of  an  anesthetic  than  females;  muscular  and 
stout  subjects  more  than  thin;  plethoric  more  than 
anemic;  nervous  more  than  sanguine;  those  poor 
in  intellectual  development  more  than  the  highly 
developed;  the  healthy  more  than  those  suffering 
from  prolonged  illness;  the  non-septic  more  than 
the  septic,  though  it  occasionally  occurs  that  some 
septic  individuals  require  a  surprisingly  large 
quantity  of  ether;  those  addicted  to  the  use  of 
drugs,  as  alcohol,  morphine,  more  than  those  not 
so  addicted.^^  (Groldau.)  Do  not  administer  chlo- 
roform from  a  towel.  An  overdose  is  too  easily 
given  this  way.  "Chloroform  usually  kills  by  its 
depressing  action  on  the  heart,  and  it  seems  highly 
probable  that  it  often  does  this  by  the  property 
which  it  has  been  shown  to  have,  of  destroying  the 
contractile  power  of  the  cardiac  muscle  when  it 
reaches  it  in   a  sufficiently  concentrated  form.'' 


POINTS    CONCERNING    CHLOROFORM.  79 

(Am.  Text  Book  of  Surg.)  By  autopsies  and 
experiments  Heintz  (Journ.  de  Med.  et  Chir.  Prat., 
October  9,  1898)  lias  proven  that  chloroform  in- 
haled for  long  periods  produces,  through  a  slow 
secondary  action,  pathological  changes  in  the 
organs,  capable  of  causing  death,  one  or  several 
days  after  the  anesthesia.  By  lessening  the  dose  of 
chloroform,  the  liability  to  undesirable  after-effects 
is  lessened.  In  the  causation  of  vomiting  after 
ether  or  chloroform  anesthesia,  one  of  the  most 
important  etiological  factors  is  the  amount  of 
anesthetic  used. 

2.  Avoid  the  continuous  action  of  chloroform 
on  the  organs  by  allowing  at  least  one  week  to 
elapse  between  two  chloroformizations  in  the  same 
individual.  The  elimination  of  chloroform  inhaled 
is  only  completely  eifected  in  about  a  week.  The 
secondary  action  of  chloroform  exhausts  itself  also 
in  about  a  week.  Both  elimination  of  the  chloro- 
form inhaled  and  its  secondary  action  must  be  at 
an  end  before  more  chloroform  is  introduced  in 
the  system.  Schenck  objects  forcibly  to  the  prac- 
tice common  in  gynecological  clinics  of  narcotizing 
individual  patients  frequently  at  short  intervals  for 
the  purpose  of  establishing  a  positive  diagnosis. 

3.  Always  be  very  watchful  while  administering 
chloroform,  and  in  fact  any  anesthetic,  to  indi- 
viduals  suffering  from  renal  or  hepatic   insuffi- 


80  GENERAL    AND    LOCAL    ANESTHESIA. 

ciency.  These  subjects  offer  to  chloroform^  as 
they  also  do  to  other  intoxicants,  as,  for  instance, 
sepsis,  an  impaired  resistance. 

4.  Use  an  Esmarch  inhaler  in  administering 
chloroform.  "Esmarch  chloroform  mask  is  the 
cleanest,  safest  and  best."  (Mellish.)  Put  two  or 
three  thicknesses  of  ganze  over  the  mask.  Change 
gauze  for  each  anesthesia.  Should  the  patient 
vomit  in  the  mask  and  soil  the  gauze  during  the 
course  of  anesthesia,  change  the  latter.  Give  this 
agent  well  diluted  with  air.  Give  it  drop  by  drop; 
the  danger  of  an  overdose  is  thereby  lessened.  In 
the  absence  of  a  clrop-bottle,  use  a  one  or  two- 
ounce  bottle  and  an  ordinary  cork.  Cut  a  shallow^ 
groove  on  one  side  of  the  cork,  and  put  in  this 
groove  either  a  thick  silk  ligature  or  a  small  strip 
of  gauze  extending  into  the  chloroform.  Cut  a 
shallower  groove  on  opposite  side  of  cork.  In 
partial  inversion  of  the  bottle,  the  chloroform  will 
flow  from  bottle  drop  by  drop.  The  rapidity  of 
outflow  is  controlled  by  the  position  of  the  bottle. 
"Quantity  is  the  all  important  factor  in  chloroform 
anesthesia.  I  am  convinced  that  death  is  nearly 
always  due  to  unskillful  administration,  and  that 
unskillful  administration  is  the  administration  of 
an  overdose."  (Waller.)  Chloroform  should 
always  be  given  with  about  95  per  cent  of  air. 
Paralysis  of  the  heart  may  result  from  the  inhala- 
tion of  too  concentrated  chloroform  vapor.   From 


POINTS    CONCERNING   CHLOROFORM. 


81 


six  to  ten  minutes  are  usually  required  to  secure 
surgical  anesthesia  by  the  aid  of  chloroform. 

At  the  beginning  of  anesthesia,  hold  inhaler 
some  inches  from  mouth  and  nose,  so  that  chloro- 
form will  be  diluted  with  air.  By  doing  this,  the 
sense  of  suffocation  which  is  so  trying  to  the 
patient,  and  so  provocative  of  struggling,  will 
often  be  prevented.  Asphyxia  taking  place  within 
a  few  minutes  from  the  commencement  of  the 
anesthesia  can  be  caused  by  a  too  highly  concen- 
trated vapor  of  chloroform.  If  the  patient  strug- 
gles violently,  breathes  irregularly,  or  holds  his 
breath,  remove  the  cap  and  let  him  take  a  breath 
of  fresh  air  before  administration  is  proceeded 
with.  In  beginning  anew  to  place  the  chloroform- 
mask  over  the  face  of  a  patient  upon  whom  its  use 
has  been  discontinued  on  account  of  some  serious 
signs,  the  vapor  should  be  carefully  and  slowly 
given,  otherwise  fatal  syncope  may  follow  in  a 
heart  already  affected  by  a  previous  overdose. 

5.  The  following  conditions,  occurring  under 
chloroform  anesthesia,  are  signs  of  impending 
danger: 

(a)  Sudden  and  complete  dilatation  of  the  pupil. 

(b)  Shallow,  sighing  respirations. 

(c)  Absence  of  pulse;  rapid,  irregular  or  inter- 
mittent pulse. 

(d)  Sudden  paleness  or  sudden  lividity  of  coun- 
tenance. 


82  GENERAL    AND    LOCAL    ANESTHESIA. 

A    FEW    POINTS    CONCERNING   ETHER   ANESTHESIA. 

To  administer  etlier  you  can  nse  a  cone,  in  the 
apex  of  Y\'liich  yon  stnS  some  ganze  sponges.  The 
Allis*  inhaler  is  a  good  apparatus.  Complicated 
inhalers  are  cumbersome,  they  have  no  distinct 
adyantage  and  have  many  decided  disadvantages. 
(Hare.)  The  requirements  of  an  ether  inhaler  are 
simplicity,  cleanliness,  inexpensiveness,  portability 
and  adaptability  to  safe  etherization. 

With  it,  the  amount  of  air  can  be  easily  and 
quickly  regulated.  With  it  anesthesia  is  begun 
by  a  free  administration  of  air  and  drop  by  drop 
administration  of  ether  upon  parallel  bandages. 
Drops  are  rapidly  increased  in  number,  so  that  by 
the  end  of  the  first  half  minute  a  tiny  stream, 
resembling  a  bead-like  chain,  will  be  going  into  the 
inhaler.  At  the  same  time  the  top  of  the  latter  is 
gradually  closed  in  and  the  administration  of  air 
is  thus  shut  off. 


*The  advantages  claimed  for  this  inhaler  by  Dr.  Allis 
are: — It  gives  the  patient  the  freest  access  of  air.  It 
is  a  mistake  to  suppose  that  air  must  be  excluded. 
All  that  is  necssary  is  that  the  air  should  be  saturated 
with  the  vapor  of  ether.  The  inhaler  affords  a  series 
of  thin  surfaces  upon  which  the  ether  can  be  poured, 
and  from  which  it  will  almost  instantly  evaporate.  By 
leaving  the  instrument  open  at  the  top,  the  supply  can 
be  kept  up  constantly,  if  desired;  and  as  ether  vapor 
is  heavier  than  air,  there  is  no  loss  by  not  coveiing  it. 
The  top  should  never  be  covered.  The  inhaler  does  not 
cover  the  patient's  eyes,  does  not  terrify  him,  and  he 
often  passes  under  the  influence  of  the  anesthetic 
without  a  struggle. 


POINTS   CONCERNING   ETHER.  83 

If  ordinary  cone  is  used,  the  ether  is  poured  on 
the  gauze  sponges  and  distributed  as  evenly  as 
possible.  New  gauze  sponges  should  be  used  for 
each  case.  Ether  should  be  given  so  that  air  is 
present  in  the  proportion  of  about  5  per  cent  while 
patient  is  struggling.  Always  begin  administering 
ether  slowly,  increasing  the  amount  gradually. 
The  inhalation  of  ether  is  made  unnecessarily  dis- 
agreeable by  those  who  brutally  insist  on  employ- 
ing the  so-called  rapid  method,  accomplished  by 
crowding  the  cone  tightly  over  the  patient's  face, 
and  holding  it  there  in  spite  of  his  most  strenuous 
efforts  to  secure  comfortable  inspirations.  (Gal- 
lant.) Air  slightly  impregnated  Avith  ether  is  the 
first  rule,  and  ether  impregnated  with  air  the 
second.  In  using  ether  do  not  drench  patient  with 
the  anesthetic.  In  giving  ether,  it  is  the  safest 
way  to  give  with  the  first  few  inspirations  vapor 
much  over-diluted  with  air  and  gradually  and 
systematically  increase  the  strength  of  vapor  at 
each  following  inspiration.  If  at  the  beginning  of 
anesthesia  ether  vapor  be  inhaled  in  too  concen- 
trated a  form  it  usually  excites  a  momentary  arrest 
of  respiration  and  a  decided  sense  of  suffocation. 
These  phenomena  are  due  to  the  irritating  action 
of  ether  vapor  upon  the  mucous  air  passages.  If 
the  patient  coughs  or  holds  his  breath,  the  vapor 
is  too  strong.  The  inhaler  should  be  removed  and 
gradually   brought   closer  again.     Impress  upon 


84  GENERAL    AND    LOCAL    ANESTHESIA. 

patient  that  lie  is  perfectly  safe^,  and  encourage 
him  to  breathe  deeply.  Ether,  being  irritating  to 
mucous  membranes,  can,  if  given  too  strong,  cause 
spasm  of  glottis  and  other  serions  reflex  acts.  Once 
patient  is  nnder  the  influence  of  ether,  decrease 
the  dose  inhaled  and  keep  the  patient  anesthetic 
and  docile  with  as  small  a  quantity  as  possible. 
On  the  average,  eight  to  flfteen  minutes  are  con- 
sumed in  producing  ether  anesthesia  (12J  min. 
Anna  E,  Blount.)  In  ether  anesthesia  the  varia- 
tions of  the  pupil  do  not  possess  the  significance 
that  they  do  in  choloroform  anesthesia.  Hence 
the  giving  of  atropine,  though  it  dilates  the  pupil 
does  not  complicate  the  anesthesia  as  much  as  it 
would,  if  chloroform  were  the  agent  inhaled.  In 
one  hundred  cases  in  which  C.  L.  Gibson  gave 
atropine  previous  to  the  etherization,  he  noticed 
that  it  did  not  prevent  vomiting,  that  it  lessened 
the  bronchorrhea,  that  it  acted  as  an  efficient  stim- 
ulant. The  administration  of  atropine  can  be 
serviceable  as  an  aid  in  preventing  bronchial  com- 
plications. AYhen  ether  is  given  in  abdominal 
operations,  atropine  prevents  an  hypersecretion  of 
mucus.  Atropine  by  j)reventing  the  plugging  of 
the  bronchi,  which  often  results  from  an  hyperse- 
cretion of  mucus,  lessens  the  liability  to  pulmonary 
complications.  These  conditions  are  serious  after 
abdominal  operations,  owing  to  the  want  of  expell- 
ing   power    from    inhibition    of    the    abdominal 


POINTS    CONCERNING   ETHER.  ^^ 

muscles.    When  giving  ether,  avoid  proximity  of 
lighted  gas  jets,  candles,  etc. 

Pulmonary  complications  following  etherization 
are  less  likely  to  occur  if  care  is  taken  to  see  that 
the  patient  who  has  taken  ether  is  not  exposed  to 
draughts  and  is  not  allowed  to  go  out  into  the 
cold  or  moist  air,  immediately  after  taking  the 
anesthetic. 

"The  following,"  according  to  Anders,  "are  the 
chief  causal  factors  of  ether-pneumxonia: 

"(a)  The  carrying  of  the  patient  from  a  warm 
operating  room  through  a  cold  corridor  to  a  room 
or  ward  with  a  lower  temperature. 

"(b)  Exposure  to  cold  during  a  protracted  oper- 
ation (catching  cold). 

"(c)  Bronchitis,  coryza,  or  other  morbid  state 
of  the  respiratory  mucosa,  at  the  time  of 
anesthesia. 

"(d)  Dried  secretions  or  incrustations  of  foreign 
matter  that  are  loosened  by  the  ether  and  drawn 
downward  into  the  lungs,  particularly  if  the  head 
be  not  kept  comparatively  low  and  turned  from 
time  to  time. 

"(e)  Use  of  ether  in  abdominal  operations — 
partly  due  to  the  more  protracted  etherization, 
thus  rendering  the  bronchi  more  susceptible; 
partly  due  to  the  fact  that,  after  these  operations, 
coughing   excites   great   pain,   and   hence   is   re- 


86  GENERAL    AND    LOCAL    ANESTHESIA. 

strained^   with  retention   of  the  bronchial  secre- 
tions."^ 

POST-AXESTHETIC     TREATMENT. 

1.  After  the  patient  is  returned  to  his  bed,  the 
anesthetist  or  an  attendant  must  remain  with  him 
until  he  recovers  consciousness,  in  order  to  guard 
against  his  choking  by  vomiting,  to  guard  against 
dropping  backward  of  the  tongue,  and  to  detect 
and  control  hemorrhage  should  it  occur.  No 
pillow  should  be  placed  under  his  head  before  he 
recovers  full  consciousness.  A  pillow  placed  below 
the  head  lessens  the  caliber  of  the  air-passages, 
embarrasses  respiration,  thereby  retarding  recovery 
from  the  effects  of  the  anesthetic.  Have  the  bed 
wJirmed,  using  hot  bricks  or  hot  water-bottles.  If 
the  operation  has  been  attended  by  much  loss  of 
blood,  elevate  the  foot  of  the  bed,  give  normal 
saline  solution  per  rectum  or  subcutaneously. 
The  garment  which  has  been  saturated  with 
patient^s  perspiration  during  the  operation,  or 
wet  by  the  irrigating  solutions,  should  be  removed 
immediately  upon  completion  of  the  operation  and 
a  warm,  dry  nightdress  substituted. 

Immediately  after  discontinuance  of  the  anes- 
thetic, if  the  nature  of  the  operation  permits  it, 
turn  patient  on  the  side,  or  if  this  cannot  be  done, 
turn  the  face  to  one  side.  Through  this  procedure, 
the  mucus  tends  to  flow  out  of  the  mouth,  the 
tongue  gravitates  into  the  cheek  of  dependent  side. 


POST-ANESTHETIC   TREATMENT. 


87 


the  respiration  is  iin  obstructed  and  the  stertor 
ceases.  No  food  should  be  giA^en  nntil  the  patient 
calls  for  it.  The  taste  of  ether  is  best  overcome 
by  moistening  the  lips  with  lemon  jnice.  After 
vomiting  has  stopped,  water  can  be  given  freely 
to  the  patient.  If  the  stomach  is  nnretentive,  water 
can  be  given  in  the  form  of  normal  saline  solntion 
per  rectum.  This  raises  the  arterial  tension, 
quenches  thirst  and  expedites  the  elimination  of 
the  anesthetic  from  the  system. 

If  during  the  course  of  the  anesthetic,  some  of 
the  anesthetic  has  fallen  into  the  conjunctival  sac, 
to  prevent  a  conjunctivitis,  instill  a  few  drops  of 
2  per  cent  sterile  cocaine  solution  in  conjunctival 
sac.  For  erythema  or  dermatitis  due  to  the  action 
of  the  anesthetic  vapor,  use  zinc  oxide  ointment. 

On  the  day  following  the  administration  of  the 
anesthetic,  I  give  a  saline  cathartic  and  a  diuretic 
mixture,  so  as  to  secure  as  thorough  elimination 
as  possible  of  the  anesthetic  agent.  The  anesthetic 
is  not  eliminated  entirely  by  the  lungs;  the  other 
excretory  organs  aid  in  its  elimination.  "Water 
should  be  given  per  os  and  rectum  as  freely  as 
practicable,  after  anesthesia,  as  an  aid  to  the 
emunctories.^^    (Mellish.) 

ACCIDENTS. 

The  accidents  of  anesthesia  admit  of  the 
following  classification:  Immediate  and  late. 
Immediate  accidents  are  those  that  occur  during 


8B  GENERAL    AND    LOCAL    ANESTHESIA. 

the  inhalation  of  the  anesthetic  or  before  the 
patient  has  recovered  consciousness.  In  meeting 
these  accidents  keep  cool,  and  remember  that 
l^romptitude  of  action  is  imperative.  For  example, 
in  cessation  of  breathing,  artificial  respiration 
must  be  practiced  immediately,  as  chloroform  can 
kill  the  patient  between  the  suspension  of  respir- 
ation and  its  attemj^ted  restoration  by  artificial 
means.  As  a  rule,  in  t  he  minor  accidents  of 
anesthesia,  what  the  patient  needs  is  more  air. 
These  minor  accidents  disappear  if  the  anesthetic 
be  withdrawn  entirely. 

1.  Ether,  being  explosive,  if  administered  near 
a  lighted  candle  or  other  flame,  an  explosion  can 
occur.     If  it  does, 

(a)  Instantly  cover  patient's  face  with  towel 
or  pillow  to  prevent  burning. 

(b)  Remove  ether  and  ether  cone  from  vicinity 
of  flame., 

2.  During  the  period  of  muscular  rigidity 
which  precedes  that  of  relaxation,  the  breathing 
sometimes  ceases.  Dash  some  ether  on  abdomen. 
Practice  artificial  respiration  if  condition  persists. 

3.  Asphyxia. — It  is  a  grave  condition.  If  it 
be  due  to  falling  back  of  tongue,  foreign  body,  or 
other  mechanical  obstruction,  remove  the  impedi- 
ment. These  conditions  will  not  occur  if  proper 
precautions  have  been  taken.  If  asphyxia  be  due 
to  a  mechanical  obstruction,  the  obstruction  must 


ACCIDENTS. 


89 


be  removed,,  otherwise  artificial  respiration  will  be 
ineffective. 

b.  Tetanic  fixation  or  relaxation  of  respiratory 
muscles.  Practice  artificial  respiration.  Sylves- 
ter's method  is  the  method  I  have  always  used. 
Most  authorities  prefer  it  to  the  other  methods. 

4.     Syncope. 

a.  Initial. 

b.  Secondary. 

(a)  Initial  syncope,  due  to  a  sudden  arrest  of 
the  heart's  action.  This  has  only  been  observed 
in  chloroform  anesthesia.  It  occurs  at  beginning 
of  anesthesia,  and  is  attributed  by  some,  authors 
to  a  pathological  condition  of  the  nervous  system, 
favoring  an  abnormal  and  rapid  saturation  of  the 
whole  or  of  one  of  the  most  important  parts  of  the 
nervous  system. 

(b)  Secondary  syncope,  occurring  more  or  less 
rapidly  during  the  course  of  anesthesia,  and 
usually  during  the  surgical  period  when  the 
patient  is  subjected  to  the  depressing  effects  of  the 
operation,  to  hemorrhage,  etc. 

Immediately  ascertain  if  the  air  passages  are 
patent  (as  long  as  the  glottis  is  closed  no  air  can 
enter  the  lungs).  Protect  wound  by  covering  it 
with  sterile  gauze-dressing,  invert  patient,  and 
practice  artificial  respiration. 

Inversion  of  patient  is  the  most  efficient  measure 
to  re-establish  the  circulation  of  the  blood  in  the 


90  GENERAL  AND  LOCAL  ANESTHESIA. 

brain.    It  is  the  most  efficient  procedure  to  combat 
syncope.    It  slionlcl  always  be  resorted  to. 

Artificial  respiration  exercises  great  influence 
upon  the  circulation  and  the  respiration.  In 
Sylvester^s  method  of  artificial  respiration,  it  is 
important  that  the  assistant  should  grasp  the  feet 
and  keep  them  motionless.  If  this  is  done,  exten- 
sion and  upward  traction  of  arms  above  the  head 
elevates  and  dilates  the  chest.  This  holding  of  feet 
is  especially  indicated  in  children  as  the  lower 
segment  of  the  body  readily  follows  the  chest  in 
its  upward  movements.  Always  begin  artificial 
respiration  by  the  act  of  expiration.  By  beginning 
with  inspiration  you  promote  further  absorp- 
tion into  the  blood  of  the  anesthetic  vapor  present 
in  the  bronchi,  the  bronchioles  and  the  air-vesicles. 
Bring  arms  down  close  to  body,  compress  firmly 
the  thorax,  and  then  elevate  the  arms.  To  deter- 
mine the  relative  values  of  Sylvester  and  Marshall 
Hall's  method  of  performing  artificial  respiration, 
Prof.  Hare  conducted  some  experiments.  He  con- 
nected the  respiratory  tract  with  an  ordinary  gas 
meter  properly  adjusted  by  means  of  a  two-way 
tube  through  one  valve  of  which  the  air  entered 
readily,  while  it  could  only  escape  through  the 
meter.  Curare  was  used  to  prevent  voluntary 
breathing.  When  the  Sylvester  method  was  used, 
the  quantity  of  air  passing  out  of  the  chest 
equalled    62,   when   that   of   Marshall   Hall  was 


MEASURES  TO  COMBAT  SYNCOPE. 


91 


employed  the  quantity  was  represented  by  22.  In 
another  experiment  the  Sylvester  method  gave  18, 
while  the  Marshall  Hall  gave  8.  It  is  evident, 
therefor,  that  the  Sylvester  is  actually  by  far  the 
best  method. 

OTHER  MEASURES  TO  COMBAT  SYNCOPE. 

1.  Medicinal  measures  may  be  used.  You  must 
not  rely  on  them  exclusively.  Strychnine  sulphate 
is  the  best  agent;  it  raises  arterial  tension  and 
deepens  the  respirations.  Digitalis  and  ammonia 
may  be  used.  Avoid  injecting  your  restorative 
agents  directly  into  a  nerve  or  a  blood-vessel,  so 
as  not  to  provoke  a  neuritis,  so  as  not  to  intoxicate 
your  patient. 

2.  Excitation  of  skin  by  various  agents.  Heat, 
cold,  liaggellations,  electricity. 

3.  Stretching  or  divulsion  of  the  sphincter  ani. 
Its  value  is  greatly  exaggerated,  although  it  does 
effect  the  respiratory  function.  Its  action,  how- 
ever, in  very  deep  narcosis  is  doubtful.  For  discus- 
sion on  this  procedure,  see  Transactions  American 
Inst,  of  Homceopathy— 1896,  1897. 

4.  Insufflation  of  air  into  the  lungs  through 
the  trachea.  Introduce  catheter  or  similar  body 
into  trachea  and  insufflate  air  either  with  mouth 
or  with  bellows.    An  excellent  method. 

5.  Laborde's  method  of  rhythmical  traction  of 
tongue.    Tip  of  tongue  being  grasped,  it  is  drawn 


93  GENERAL    AND    LOCAL    ANESTHESIA. 

out  of  moutli  regularly  sixteen  times  a  minute  and 
by  reflexly  stimulating  the  respiratory  center,  it 
renews  respiratory  moyements  in  apparently  hope- 
less cases.  The  tongue  must  neither  he  lacerated 
nor  contused.  The  tractions  must  not  be  precipi- 
tate. They  must  be  performed  methodically  and 
rhythmically. 

6.  Massage  and  compression  of  heart.  Kapid 
friction  over  region  of  heart.  Heat  over  cardiac 
region.  Rub  the  extremities  strongly  toward  the 
heart.  Comj)ress  the  abdominal  aorta.  These  last 
two  methods  are  intended  to  keep  the  blood  in 
the  region  of  the  heart  and  great  nerve  centers, 
where,  at  least,  during  the  period  of  shock,  its 
presence  is  vitally  important. 

If  the  above  methods  fail  to  restore  respiratory 
action,  the  i^atient  must  not  be  abandoned  until 
tracheotomy  followed,  if  necessary,  by  prolonged 
artificial  respiration,  or  insufflation  has  been  re- 
sorted to.  Tracheotomy  facilitates  the  access  of 
air  to  the  lo^\  er  respiratory  regions.  The  accumu- 
lation of  mucus,  the  falling  backward  of  the 
tongue,  the  constriction  of  the  jaws  and  other 
causes  contributing  to  the  obstruction  or  closure 
of  the  glottic  orifice,  renders  the  passage  of  air  to 
the  lungs  through  the  upper  respiratory  passages 
difficult,  if  not  impossible.  This  operation,  sup- 
plying a  new  route,  meets  an  important  indication. 
The  operation  is  benign.     Being  practiced  upon 


Vomiting  after  anesthesia.  9S 

sound  tissues,  the  canula  can  soon  be  removed  after 
recovery  of  the  patient  from  anesthesia,  and  heal- 
ing by  first  intention  results  early. 

7.  Dupage  in  cardiac  syncope  occurring  under 
anesthesia  advises  that  normal  saline  solution  be 
injected  in  the  internal  saphenous  vein.  He 
expects  by  this  to  excite  the  endothelium  of  the 
cardiac  cavities. 

YOMITING    AFTER    ANESTHESIA. 

"There  is  no  specific  to  prevent  vomiting  after 
anesthesia."    (Cheever.) 

Iv  The  following  procedure  is  often  very 
serviceable  and  effective.  Saturate  a  towel  with 
fresh,  strong  vinegar,  and  hold  it  a  few  inches 
above  patient's  face.  It  should  be  used  directly 
after  the  administration  of  the  anesthetic  has  been 
discontinued,  and  kept  up  as  long  as  indicated.  It 
is  free  from  toxic  effects  and  can  occasion  no  harm- 
ful conditions.  The  theoretical  explanation  of  its 
action  is  that,  free  chlorine,  one  of  the  decompo- 
sition products  of  chloroform,  is  neutralized  by  the 
acetic  acid.  (Lewin.)  Chlorine  acts  as  a  marked 
irritant  to  the  pharyngeal  mucous  membrane  and 
induces  vomiting,  but  the  acetic  acid  soothes  the 
irritated  parts  and  neutralizes  the  chlorine  at  the 
same  time. 

It  has  also  been  claimed  that  vinegar  by  its 
pungency  stimulates  the  respiratory  mucous  mem- 


94  GENERAL    AND    LOCAL    ANESTHESIA. 

brane,  promotes  normal  secretion  and  by  its  sooth- 
ing action  on  peripheral  nerve  filaments  of  part, 
lessens  the  irritability  of  the  pneumogastric  and 
of  its  centers  and  thereby  controls  reflex  condition 
of  vomiting. 

2.  Application  of  mnstard  plaster  to  hypogas- 
trinm. 

3.  Acetanilid. 
Caffeinae  cit. 

Camphor  monobr.  aa  grj.   every  hour  till 
vomiting  ceases. 

4.  Cerium  oxalate. 

5.  Gastric  lavage,  with  lukewarm  solution,  may 
be  done  while  patient  is  yet  unconscious. 

6.  Hot  water  with  sodium  bicarbonate.     (Par- 
menter.) 

7.  Wine  of  ipecac — one  drop  on  tongue  every 
hour  for  two  or  three  hours. 

8.  Crushed  ice. 

9.  Cocaine  hydrochlorate,  gr.  i. 

To  avoid  nausea  and  vomiting  after  anesthesia, 
Blumfield  (Lancet)  gives  the  following  directions: 

1.  Use  as  little  of  the  anesthetic  as  possible 
consistent  with  perfect  anesthesia. 

2.  Wash  out  the  stomach  at  the  close  of  the 
operation,  when  much  mucus  has  been  swallowed. 

3.  Move  patient  about  as  little  as  possible  dur- 
ing and  after  the  operation. 

4.  Place  him  on  his  right  side  in  bed. 


OTHER   COMPLICATIONS.  95 

5.  Avoid  altering  the  temperature  of  the  room 
for  several  hours. 

Late: 

Headache.  Usually  requires  a  night's  rest  for 
its  removal.     Coal  tar  products  are  of  service. 

Loss  of  blood,  or  shock  from  a  prolonged  oper- 
ation, are  combatted  by  high  rectal  injections  of 
normal  saline  solution.  This  solution  can  be  used 
in  severe  cases  subcutaneously  or  intravenously. 
Use  it  hot  (110-115°  F.). 

Anesthetic  chill  (rare). — In  many  cases  the  chill 
is  chiefly  due  to  the  operation.  Warm  bricks,  hot 
water  bottles,  rubbing  of  body  with  alcohol,  rub- 
bing with  warm  camphorated  oil. 

Anesthetic  stupor. — If  this  state  is  prolonged, 
patient  must  be  stimulated,  rubbed  with  alcohol, 
made  to  inhale  plenty  of  fresh  air,  gentle  flagella- 
tion of  thorax  resorted  to. 

Persistent  singultus. — Dram  doses  of  Hoffman's 
anodyne.    Musk,  chloral. 

Jaundice. — No  special  treatment. 

Post-anesthetic  paralysis.  —  That  of  similar 
paralysis  due  to  other  causes.  Treatment  of  post- 
anesthesia paralysis  should  be  preventive  as  avoid- 
ing forced  elevation  of  arm,  watching  to  see  that 
the  arm  or  member  is  not  compressed  against  edge 
of  table,  etc.,  etc.  "The  best  treatment  of  paralysis 
following  anesthesia  consists  in  guarding  the 
patient    while    unconscious    from    the    injurious 


96  GENERAL    AND    LOCAL   ANESTHESIA. 

effects  of  pressure  produced  by  unnatural  posi- 
tions/^ (Mally.)  "Local  faradization  is  indicated 
in  paralysis  from  compression,  and  passive  move- 
ment of  the  articulation  to  prevent  stiffness.  If 
the  electric  tests  disclose  degenerative  atrophy  or 
severe  reflex  paralysis,  localized  electric  treatment 
is  contraindicated.  In  the  latter  case,  the  reflex 
medullary  irritability  should  be  soothed  with  static 
electricity,  and  possibly  revulsion  on  the  spine 
with  spark  friction."    (Mally,  Eevue  de  Chirurgie.) 

Albuminuria  and  Glycosuria  may  follow  the 
administration  of  ether  or  chloroform.  They  are 
usually  temporary  conditions.  For  treatment, 
consult  text-books  on  practice  of  medicine. 

Finally  allow  me  to  quote,  from  J.  W.  Gruest, 
eleven  don^ts  for  the  anesthetist: 

"1.     Don't  go  to  sleep  yourself. 

"2.     Don't  neglect  your  patient. 

"3.     Don't  be  overconfident.    It  is  best  to  fear. 

"4.  Don't  allow  friends,  relatives  or  the  sur- 
geon himself  to  alter  your  judgment  in  the  admin- 
istration. 

"5.  Don't  stimulate  your  patient  immediately 
preceding  the  administration  of  the  anesthetic. 

"6.     Don't  overdose  him  through  anxiety. 

"7.  Don't  give  him  morphia  or  atropia  (unless 
specially  indicated).  Pupil  should  not  be  benumbed 
by  morphine  previous  to  the  operation. 


BROMIDE   OF   ETHYL. 


97 


"8.  Don't  forget  false  teeth  and  foreign  bodies 
in  the  patient's  mouth. 

"9.  Don't  tell  the  relatives  that  there  is  no 
danger.    There  is  always  danger. 

"10.  Don't  fail  to  make  a  physical  examination 
of  the  patient  yourself. 

"11.  Don't  leave  your  patient  too  soon  after 
anesthesia." 

Beomide  of  Ethyl. 

The  usefulness  of,  and  the  indications  for,  the 
employment  of  ether  and  chloroform,  I  have 
already  somewhat  exhaustively  discussed.  They 
have  an  established  sphere  of  indications.  Yet 
it  is  my  opinion,  based  on  clinical  observa- 
tion, that  the  comfort  and  the  safety  of  the 
patient,  as  well  as  the  convenience  and  ease  of 
mind  of  the  operator,  can  often  be  promoted  by 
using,  in  appropriate  cases,  ethyl  bromid  instead 
of  chloroform  or  ether.  Many  operations  do  not 
demand  the  long  anesthesia  of  ether  with  its  at- 
tendant discomforts,  nor  do  they  warrant  submit- 
ting the  patient  to  the  dangers  of  chloroform  anes- 
thesia. Hence,  an  hiatus,  which  in  the  present 
state  of  our  knowledge  can  often  be  filled  by  the 
use  of  ethyl  bromide.  It  is  an  agent  well  adapted 
to  secure  anesthesia  for  operations  of  short  dura- 
tion. It  is  an  agent  especially  well  adapted  for 
use  in  children  and  young  adults. 


98  GENERAL    AND    LOCAL    ANESTHESIA. 

PEOPEKTIES    OF   ETHYL   BROMIDE,  j 

Ethyl  bromide  (chemically  C^B-^Bt)  is  a  very 
volatile  liquid,  having  a  very  agreeable  odor  and  a 
non-saccharine  taste.  It  has  a  density  of  1.40  and 
a  boiling  point  of  40.70.  It  has  the  great  advan- 
tage over  nitrous  oxide  of  portability  and  simplic- 
ity as  regards  the  apparatus  required  for  its  admin- 
istration. Its  use  requires  no  special  apparatus. 
Our  text-books  on  surgery  mention  the  agent  but 
fail  to  give  the  technique  of  its  administration  and 
fail  to  give  it  the  consideration  which  it  deserves. 
It  is  a  general  anesthetic,  the  popularity  of  which 
is  increasing.  It  is  an  innocent  anesthetic  on  con- 
dition that  its  inhalation  is  of  short  duration  and 
that  it  is  adminstered  properly.  If  it  is  not  admin- 
istered properly,  its  use  is  unsatisfactory  to  the 
operator  and  dangerous  to  the  patient. 

Dr.  Chisholm  has  used  it  in  3,000  cases  without 
fatal  or  untoward  results  occurring  during  or 
after  its  use.  Gilles  collected  20,000  bromide 
ethylizations  without  a  death.  Eeich  went  over 
the  literature  and  found  16  deaths  had  occurred  in 
60,000  administrations.  In  some  of  these  16  cases, 
the  anesthetic  had  been  administered  faultily,  in 
others  an  impure  or  decomposed  preparation  had 
been  used,  and  in  a  few  cases,  the  deaths  were  di- 
rectly traceable  to  the  anesthetic.  I  have  used  the 
agent  myself  and  have  seen  it  used  frequently  in 


PROPERTIES  OF  ETHYL  BROMIDE.  99 

Prof.  Coulter's  and  Prof.  Hawley's  nose  and  throat 
clinics  and  I  have  never  seen  any  ill-resnlts  from 
its  use. 

With  bromide  of  ethyl  as  with  other  anesthetics, 
experience  is  required  to  be  able  to  nse  it  to  the 
best  advantage,  and  with  the  greatest  safety  to  the 
patient.  It  exerts  no  notable  inflnence  npon  the 
inhalant's  temperature.  It  exerts  no  modifying 
influence  on  the  secretions.  In  some  individuals, 
its  use  provokes  marked  sweating.  Its  stage  of 
excitement  is  of  a  very  transient  character.  Owing 
to  the  fact  that  it  does  not  secure  complete  muscu- 
lar relaxation,  that  it  does  not  relax  muscular 
spasm,  it  is  not  of  aid  in  the  diagnosis  of  fractures 
and  dislocations^  and  can  not  be  utilized  in  effect- 
ing the  reduction  of  these  conditions.  Outside 
of  slightly  accelerating  the  pulse,  it  has,  in  thera- 
peutic doses,  no  special  action  on  the  heart.  In 
toxic  doses,  it  is  a  cardiac  depressant.  It  acceler- 
ates the  respirations.  It  has  a  marked  depressant 
action  on  the  respiration  only  when  large  and 
practically  excessive  doses  are  taken.  Death  is 
caused  by  the  toxic  action  of  the  drug  on  the 
respiratory  center.  It  is  eliminated  by  the  lungs. 
Owing  to  its  great  volatility,  it  is  rapidly  elimi- 
nated. "Bromide  of  ethyl  is  almost  totally  elim- 
inated by  the  respiratory  organs."  (Ch.  Eobin.) 
Traces  of  it  have  been  found  in  the  renal  secre- 
tion. "  i 


100  GENERAL    AND    LOCAL    ANESTHESIA. 

ADVANTAGES    OF   ETHYL   BROMIDE   AS   A    GENERAL 

ANESTHETIC. 

(1)  Simplicity  of  use.  Technique  of  admin- 
istration is  easily  acquired.  If  during  the  inhal- 
ation of  this  agent,  accidents  should  occur,  they 
are,  owing  to  the  great  volatility  and  rapid  elimi- 
nation from  the  system  of  bromide  of  ethyl,  rap- 
idly recovered  from. 

(2)  Under  its  use,  the  performance  of  opera- 
tions upon  patients  in  the  sitting  posture  is  per- 
missible. This  posture,  though  not  as  favorable 
as  the  recumbent  posture,  is  not  dangerous  for 
bromethylized  patients,  owing  to  the  fact  that 
bromid  of  ethyl  produces  cerebral  congestion  and 
not  cerebral  anemia.  This  agent,  unlike  chloro- 
form, is  not  a  predisposant  to  syncope.  With 
ether  anesthesia,  the  sitting  posture  is  undesirable; 
with  chloroform,  it  is  positively  dangerous.  The 
maintenance  of  the  patient  in  the  sitting  posture 
is  of  great  convenience  to  the  operator  for  the  per- 
formance of  operations  in  the  naso-pharynx,  such 
as  the  removal  of  naso-pharyngeal  adenoids,  ton- 
sillotomy. The  patient's  head  and  neck  can,  at 
the  proper  time,  be  rapidly  thrown  forward,  and 
the  blood  thereby  escapes  through  the  mouth  and 
nostrils  instead  of  gravitating  in  the  stomach  or 
in  the  lungs,  as  it  is  prone  to  do  when  mouth  or 
throat  operations  are  performed  with  patients  in 
the  recumbent  j^osture. 


ANDVANTAGES   OF  ETHYL    BROMIDE.  101 

(3)  The  great  rapidity  with  which  anesthesia 
is  induced.  The  time  required  to  induce  deep  nar- 
cosis varies  from  45  seconds  to  2  minutes.  Gener- 
ally speaking  one  minute  suffices.  This  saving  of 
time  is  of  distinct  advantage  in  dispensary  and  in 
office  work,  especially  when  one  considers  that  the 
inhalation  of  this  drug,  if  it  be  pure  and  if  it  be 
employed  with  proper  precautions,  is  not  more 
dangerous  than  the  inhalation  of  ether  and  chloro- 
form. In  fact,  it  is  less  so.  An  average,  from 
8  to  15  minutes  are  required  to  produce  ether 
anesthesia. 

(4)  The  great  rapidity  with  which  conscious- 
ness is  recovered.  The  brain  recovers  its  func- 
tions perfectly,  and  quickly  after  the  deep  but  very 
transient  impression  brought  about  through  the 
inhalation  of  the  vapor  of  this  potent  agent. 
Usually  after  the  withdrawal  of  the  inhaler,  the 
patient  will  remain  unconscious  from  two  to  three 
minutes  and  will  then  promptly  return  to  con- 
sciousness. After  the  anesthetic  is  removed,  co- 
ordination of  the  muscular  movements  is  rapidly 
regained.  Five  minutes  after  the  anesthesia,  the 
patient  is  as  much  himself  as  if  no  anesthetic  had 
been  administered.  He  can  leave  the  office  and 
walk  home,  unassisted  and  unattended.  This  feat- 
ure makes  this  agent  useful  for  such  operations  as 
can  safely  be  performed  in  the  physician's  office. 

(5)  Absence   of  annoying  after  effects.     No 


102  GENERAL    AND    LOCAL    ANESTHESIA. 

shock  after  its  use.  Nausea  and  vomiting  do 
occur,  but  are  very  infrequent  if  the  drug  is  in- 
haled upon  an  empty  stomach.  If  after  its  use 
vomiting  occurs  and  persists,  relieve  it  by  having 
patient  take  a  draught  of  ice  water,  or  by  having 
him  swallow  small  pieces  of  ice.  Frequently  after 
its  use  the  patient^s  breath  for  a  few  days  has  a 
mild  garlicky  odor.  This  is  not  productive  of 
much  discomfort.  Bromide  of  ethyl  is  quite  un- 
irritating  to  the  respiratory  mucous  membrane, 
hence  its  inhalation  is  never  followed  by  bron- 
chitis, or  ether  pneumonia;  neither  is  it  followed 
by  other  such  unfortunate  post-anesthetic  com- 
plications as  nephritis. 

(6)  The  odor  does  not  remain  as  does  that  of 
ether  on  the  clothing  of  the  operator  or  on  that  of 
his  assistants.  The  odor  does  not  permeate  the 
office. 

(7)  It  can  be  safely  administered  without  as 
much  pre-anesthetic  preparation  of  the  patient  as 
is  required  for  ether  or  chloroform  anesthesia. 

DISADVANTAGES  OF  ETHYL  BROMIDE. 

(1)  It  is  not  suitable  for  prolonged  anesthesia. 
Experience  has  conclusively  demonstrated,  that  its 
use  is  dangerous  in  operations,  the  performance  of 
which  requires  more  than  a  few  minutes.  For 
prolonged  anesthesia,  this  agent  possesses  no  ad- 
vantages over  ether  or  chloroform.    It  does  pos- 


CONTRAINDICATIONS   FOR  ETHYL   BROMIDE.  103 

sess  additional  dangers.  Hence  we  shall  employ 
this  agent  only  in  those  operations  to  which  it  can 
be  adapted,  that  is,  only  in  operations  of  short 
duration.  Even  the  warmest  advocates  of  bromid 
of  ethyl  concede  that  it  should  not  be  used  as  an 
anesthetic  for  prolonged  operations.  "Its  use 
should  be  restricted  to  short  operations."  (Gleich.) 

(2)  The  use  of  bromide  of  ethyl  is  contra- 
indicated  in  individuals  having  serious  cardiac, 
renal  or  pulmonary  lesions.  Alcoholics  are  not 
favorable  subjects  for  bromethylization. 

(3)  It  does  not  secure  complete  muscular  re- 
laxation. "Bromide  of  ethyl,  as  it  often  causes 
muscular  rigidity,  should  not  be  used  in  opera- 
tions in  which  relaxation  of  the  muscles  would  be 
of  assistance."     (Dudley  Buxton.) 

(4)  It  is  easily  decomposed  by  exposure  to 
light  and  air. 

(5)  Like  ether  and  chloroform,  its  use  re- 
quires an  experienced  assistant  whose  whole  atten- 
tion must  be  given  to  the  administration  of  the 
anesthetic.  Local  anesthetics  enable  the  operator 
to  dispense  with  this  assistant. 

Bromide  of  ethyl  general  surgical  anesthesia 
(this  agent  is  also  employed  by  a  few  as  a  local 
anesthetic)  can  be  resorted  to  for  operations  such 
as  the  following:  Opening  of  superficial  abscesses, 
as  abscesses  of  the  abdominal  wall;  dilation  of  the 
sphincter  ani;  hemorrhoidal  operations;  removal 


104  GENERAL    AND    LOCAL    ANESTHESIA. 

of  urethral  polypi;  internal  iirethrotomy;  curetting 
of  sinuses;  tenotomy;  scraping  of  carbuncles;  re- 
moval of  aural  polypi  and  paracentesis  of  the 
tympanum;  ablation  of  condylomata,  etc.  Any 
painful  surgical  operation,  the  performance  of 
which  does  not  occupy  more  than  two  minutes, 
can  be  safely  and  painlessly  performed  under 
bromid  of  ethyl.  The  agent  is  particularly  adapted 
for  children  while  subjecting  them  to  short  ex- 
aminations involving  pain. 

PKOPEK  TECHNIQUE  OF  ADMINISTRATION. 

(1)  Do  not  employ  this  agent  in  eases  unsuited 
for  its  action,  for  instance,  as  for  major  operations 
lasting  more  than  a  few  minutes.  Its  usefulness 
for  long  operations  is  no  longer  debatable,  it  is 
established.  Fatalities  have  resulted  from  its  em- 
ployment in  prolonged  operations.  You  would 
not  employ  chloral  hydrate  for  the  palliation  of 
acute  pain,  you  would  employ  opium  or  one  of  its 
derivatives;  so  for  prolonged  operations  requiring 
general  surgical  anesthesia,  you  will  not  emplo;y 
bromid  of  ethyl,  you  will  employ  either  chloroform 
or  ether. 

(2)  Make  a  physical  examination  of  your  pa- 
tient. The  object  is  to  determine  whether  there 
are  contra-indications  to  the  use  of  this  joarticular 
anesthetic.  Serious  cardiac,  pulmonary  and  renal 
diseases  are  conditions  that  make  the  use  of  this 


TECHNIQUE   OF  ADMINISTRATION.  105 

agent^  as  well  as  that  of  general  anesthetics,  haz- 
ardous. In  alcoholics,  bromide  of  ethyl  provokes  a 
marked  stage  of  excitement. 

(3)  Always  be  sure  that  the  bromide  of  ethyl 
that  you  are  going  to  use  is  pure;  be  sure  that  it 
has  not  undergone  decomposition.  Impurities  may 
come  from  the  process  of  manufacture  or  may 
come  from  decomposition.  Exposure  to  air  and 
light  rapidly  decomposes  this  agent  and  results  in 
the  formation  of  compounds  having  a  more  toxic 
effect  than  ethyl  bromid.  If  you  use  one-half 
ounce  vials,  after  the  vial  has  been  used  to  anes- 
thetize one  patient,  throw  away  the  unused  por- 
tion of  the  contents.  This  is  not  extravagance; 
it  is  prudence.  "Most  of  the  unfavorable  symp- 
toms, such  as  vomiting,  are  due  not  to  the  bromide 
of  ethyl,  but  to  the  impurities  too  often  found 
associated  with  it."  (Bazy.)  Pure  bromide  of 
ethyl  has  a  perfectly  neutral  reaction  with  refer- 
ence to  litmus  paper.  It  is  colorless.  If  it  be 
yellowish,  it  is  decomposed  and  contains  free 
bromine.  This  latter  element  is  a  distinct  irritant 
to  the  respiratory  mucous  n;embranes.  As  the 
liquids  is  very  easily  decomposed,  buy  it  in  small 
colored-glass  vials  of  one-half  or  one  ounce.  The 
vials  are  sealed  by  melting  the  glass  neck  in  the 
flame. 

(4)  Never  use  bromide  of  ethylene  instead  of 
bromide  of  ethyl.   These  substances  are  dissimilar 


106  GENERAL    AND    LOCAL   ANESTHESIA. 

compounds.  The  former  is  chemically  represent- 
ed by  CJIJ^To',  the  latter,  by  CJI^Bt.  Bromide 
of  ethylene  is  not  only  a  poor  anesthetic,  but  it 
is  also  a  very  dangerous  agent.  It  has  caused 
deaths. 

(5)  The  drug  is  to  be  inhaled  upon  an  empty 
stomach.  When  practicable  the  taking  of  solid 
food  should  be  avoided  by  the  patient  for  four 
hours,  and  liquid  food  for  three  hours,  before  the 
administration.  If  the  drug  is  inhaled  upon  a  full 
stomach,  nausea  and  vomiting  are  apt  to  follow 
its  use.  The  most  opportune  time  for  the  induc- 
tion of  general  anesthesia  is  when  the  patient  is 
rested  and  when  his  stomach  is  empty. 

(6)  Have  the  patient  urinate  previous  to  start- 
ing the  anesthesia.  This  lessens  the  liability  to 
involuntary  emission  of  urine  during  anesthesia. 
This  accident,  when  it  occurs,  is  always  very 
embarrassing,  especially  so  in  female  patients. 

(7)  In  the  absence  of  a  special  indication  for 
the  employment  of  any  other  position,  the  recum- 
bent posture,  with  slight  elevation  of  the  head,  is 
the  posture  of  election.  It  is  more  convenient  for 
the  operator;  it  is  safer  for  the  patient.  If  the 
patient  be  a  child,  and  the  operation  be  one  in 
the  buccal  cavity,  demanding  that  anesthesia  be 
secured  with  the  patient  in  the  sitting  posture, 
wrap  a  sheet  around  the  patient^s  neck  and  chest 
so  as  to  include  and  prevent  the  movement  of  the 


TECHNIQUE   OF  ADMINISTRATION. 


107 


arms.  The  child  is  then  taken  upon  the  nurse's 
lap,  its  legs  being  placed  and  immobilized  between 
the  nurse's  thighs.  The  nurse's  left  arm  encircles 
the  child's  chest  to  prevent  struggling  and  move- 
ments of  arms,  and  her  right  hand  immobilizes  the 
child's  head  on  her  right  shoulder.  This  is  same 
position  that  is  employed  for  the  intubation  of 
children. 

(8)  All  constrictions  about  the  neck,  the  chest 
or  the  abdomen  are  to  be  removed.  The  corset  is 
to  be  removed.  The  same  applies  to  any  other 
agency  interfering  with  the  respiratory  move- 
ments. Free  respiration  hastens  the  production  of 
anesthesia  and  also  facilitates,  once  the  inhaler  is 
withdrawn,  the  elimination  from  the  body  of  the 
ethyl  bromid  inhaled.  The  innocuousness  of  this 
agent  is  largely  due  to  its  great  volatility  and  to 
its  rapid  elimination  from  the  system.  Interfer- 
ence with  the  patient's  respiratory  movements  is 
not  uncommonly  due  to  a  lazy  assistant  using  the 
patient's  chest  as  an  arm  rest. 

(9)  All  foreign  bodies,  such  as  chewing  gum, 
false  teeth^  etc.,  are  to  be  removed  from  the  mouth. 
If  the  operation  is  to  be  performed  in  the  buccal, 
the  naso-pharyngeal  or  the  laryngeal  cavities,  pre- 
vious to  starting  the  anesthetic  insert  carefully 
and  gently  a  mouth  gag  with  padded  alveolar  pro- 
jections between  the  patient's  left  upper  and  lower 


108  GENERAL    AND    LOCAL   ANESTHESIA. 

molars.     With   brometliylization,   there  is   often 
mild  trismus. 

(10)  Leave  eyes  uncovered  and  watch  them. 
When  analgesia  begins  to  appear,  the  pupils  dilate 
and  the  conjunctival  vessels  become  appreciably 
congested.  The  anesthetist  is  to  watch  the  anes- 
thesia only, — the  operator  is  to  watch  the  opera- 
tion. 

(11)  The  inhaler  to  be  used  can  be  made  by 
folding  a  crash  towel  into  an  air-tight  cone.  The 
cone  is  made  almost  impervious  to  air  by  placing 
a  layer  of  paper  between  the  folds  of  the  towel. 
The  base  of  the  cone  must  be  large  enough  to  cover 
both  mouth  and  nose.  Hold  the  rim  of  the  cone 
firmly  down  upon  the  face  so  that  very  little  air 
can  enter.  The  use  of  a  cumbersome  apparatus 
for  the  administration  of  this  anesthetic  has  no 
advantage  over  that  of  a  cone  made  of  paper  and 
gauze,  or  with  paper  and  a  towel.  These  cumber- 
some apparatus  are  not  as  portable,  are  costly, 
and  are  not  as  cleanly  as  the  towel  and  paper 
cone;  neither  are  they  as  safe.  A  fresh  cone  is 
to  be  used  for  each  anesthesia. 

(12)  Operator  must  be  prepared  to  operate  as 
soon  as  narcosis  is  complete.  He  must  not  wait 
for  complete  muscular  relaxation.  Every  prepa- 
ration should  have  been  made  in  advance.  In- 
struments should  have  been  sterilized  and  ar- 
ranged in  the  order  in  which  they  are  to  be  used. 


.',,  ;  TECHNIQUE   OF  ADMINISTRATION.  109 

Surgeon  must  be  dextrous  and  thoroughly  familiar 
with  the  different  steps  of  the  operation  which 
he  is  to  perform.  No  time  must  be  lost,  as  bro- 
mide of  ethyl  anesthesia  is  a  rapidly  fleeting  anes- 
thesia. The  effects  of  it  pass  off  too  quickly  to 
make  it  of  any  service  to  slow  operators  or  for 
tedious  operations. 

(13)  Instruct  the  patient  in  advance  to  make 
deep  and  long  inspirations.  A  few  inhalations 
suffice.  The  entire  dose  of  anesthetic  is  to  be 
given  at  once.  Keep  in  mind  that  bromide  of  ethyl 
is  not  chloroform,  and  that  it  must  not  be  admin- 
istered like  chloroform.  Chloroform  must  be  ad- 
ministered by  the  drop  method,  cautiously  and 
slowly;  ethyl  bromide  must  be  administered  in 
massive  doses,  rapidly  and,  in  fact,  brutally. 
Unless  bromide  of  ethyl  vapor  is  crowded^  only  a 
state  of  semi-anesthesia  must  be  expected.  Push 
the  bromide  of  ethyl  during  the  few  moments  nec- 
essary to  produce  anesthesia.  Ethyl  bromide,  un- 
like chloroform,  should  never  be  used  with  an 
admixture  of  air.  The  admission  of  air  retards 
and  may  prevent  the  production  of  narcosis.  A 
saturated  ethyl  vapor  must  be  inhaled  to  the  ex- 
clusion of  atmospheric  air,  in  order  to  obtain 
narcosis  speedily  and  effectually. 

The  entire  dose  for  a  child  is  about  two  drams, 
for  an  adult  from  4  to  5  drachms  (as  much  as 
six  drams  can  be  used).     It  is  poured  at  once 


110  GENERAL    AND    LOCAL    ANESTHESIA. 

into  the  inhaler.  "I  pour  the  full  dose  required 
to  produce  anesthesia  into  the  inhaler,  the  dose  in 
children  ranging  from  one  and  a  half  to  two  and 
a  half  drachms,  and  in  adults  from  two  to  three 
drachms.  I  immediately  cover  the  patient's  nose 
and  mouth,  having  previously  instructed  the  pa- 
tient to  breathe  deeply.''  (Kempster.)  Apply 
cone  firmly  and  closely  to  mouth  and  nose  and  do 
not  remoove  it  until  anesthesia  is  induced.  Owing 
to  the  great  volatility  of  the  substance  (it  is  the 
most  volatile  of  the  general  anesthetics)  the  re- 
moval of  the  cone  retards  the  production  of  an- 
esthesia. If  the  cone  is  held  at  a  distance  from 
the  face  and  given  with  free  admission  of  air  to 
the  space  between  the  towel  and  face,  satisfactory 
anesthesia  will  not  be  obtained.  Once  full  anes- 
thesia has  been  induced  and  the  cone  has  been 
withdrawn,  most  authorities  condemn  its  being 
applied  to  the  face  again. 

The  first  few  inhalations  give  rise  to  a  very 
decided  flushing  of  the  face.  In  alcoholics,  there 
is  a  short  period  of  excitement.  The  agent  often 
provokes  muscular  spasms.  Do  not  be  alarmed 
by  the  presence  of  muscular  rigidity,  it  will  soon 
disappear.  The  same  stage  of  muscular  rigidity 
occurs  during  the  administration  of  other  gen- 
eral anesthetics.  The  patient  struggles  violently 
and,  to  the  uninitiated,  appears  to  be  in  danger  of 
asphyxia,  nevertheless^  the  cone  must  iiot  be  re- 


TECHNIQUE   OF  ADMINISTRATION.  Ill 

moved  until  full  anesthesia  is  induced  and  the 
struggling  has  ceased.  The  stoppage  of  all  strug- 
gling, the  absence  of  the  conjuctival  reflex,  the 
falling  down  limply  of  the  elevated  arm,  are  all 
evidences  that  inform  you  that  your  patient  is 
sufficiently  anesthetized. 

In  case  of  failure  of  respiration  occurring  in  a 
patient  inhaling  bromide  of  ethyl,  immediately 
place  the  patient  in  the  recumbent  posture  and 
proceed  to  perform  artificial  respiration.  Always 
begin  with  the  act  of  expiration;  inspiration  would 
promote  further  absorption  of  the  anesthetic. 

For  the  performance  of  artificial  respiration  in 
the  combating  of  some  of  the  accidents  incident 
to  general  anesthesia,  we  employ  either  Sylvester 
or  Laborde^s  method.  Both  methods  can  be  em- 
ployed simultaneously. 


113  GENERAL    AND    LOCAL    ANESTHESIA. 


CHAPTER  II. 
LOCAL  ANESTHESIA. 

"To  perform  operations  under  general  anesthe- 
sia when  they  are  certainly  practicable  with  one 
or  another  form  of  local  anesthesia,  I  mnst,  from 
the  standpoint  of  humanity,  denounce  as  abso- 
lutely unjustifiable.'^ — Schleich. 

Local  anesthetics  are  employed  to  abolish,  by 
their  topical  application,  the  sensibility  of  a  part 
for  more  or  less  prolonged  periods,  during  diag- 
nostic, therapeutic  and  operative  procedures  of 
various  kinds.  The  number  of  substances  that 
have  been  proposed  and  used  as  local  anesthetic 
agents  is  great.  Very  few  have  found  wide  ac- 
ceptance. Very  few  have  remained  popular  for 
any  length  of  time.  A  local  anesthetic,  to  be  ideal, 
must  meet  the  following  requirements: 

1.  Complete  abolition  of  pain. 

2.  Non-interference  with  the  operator's  pro- 
cedures. That  is,  the  operator  should  not  be 
compelled  to  modify  his  operation  on  account  of 
restrictions  imposed  by  the  local  anesthetic  agent. 

3.  Production  of  no  unpleasant  after-effects, 
either  local  or  general. 

4.  ISTon-interference  with  the  healing  process. 
We  have  yet  no  agent  that  always  meets  these 

requirements. 


ADVANTAGES   OF   LOCAL   ANESTHESIA.  113 

Among  the  less  used  agents  may  be  mentioned: 

(a)  Brucine  in  five  per  cent  solution.  This 
agent  was  abandoned  because  it  did  not  give  uni- 
form results;  it  was  not  readily  absorbed,  and  had 
none  of  the  advantages  of  cocaine. 

(b)  Beta-Eucaine  is  a  good  local  anesthetic 
serviceable  for  all  operations  upon  the  ophthalmic, 
urethral,  buccal  or  other  mucosae.  It  can  also  be 
used  intra  and  hypodermically.  It  is  said  to  cause, 
in  therapeutic  doses,  no  heart  depression  or  other 
unpleasant  systemic  effects.  It  is  less  toxic  than 
cocaine  with  almost  equal  analgesic  power,  and  can 
therefore  be  employed  in  larger  amormts  and  with 
greater  freedom,  in  such  cases  where  the  field  of 
operation  is  extensive. 

It  is  a  colorless,  crystalline  powder,  soluble  in 
30  to  33  1-3  parts  of  cold  water,  making  a  3  per 
cent  to  3-J  per  cent  solution.  Stronger  solutions 
may  be  made  with  the  aid  of  heat.  The  eucaine 
crystals  that  are  deposited  on  cooling  may  be  re- 
dissolved  by  raising  the  temperature  of  the  solu- 
tion, without  in  any  way  influencing  its  efficacy. 
It  is  3.75  times  less  toxic  than  cocaine;  it  is  at 
times  irritating  to  the  tissues;  its  injection  into 
the  tissues  also  at  times  causing  pain;  it  causes  a 
hyperemia  of  the  tissues,  the  increased  hem- 
orrhage attending  its  use  obscuring  to  a  certain 
extent  the  field  of  operation.  It  admits  of  com- 
plete sterilization  by  boiling.    This  is  a  matter  of 


114  GENERAL    AND    LOCAL   ANESTHESIA. 

much  importance,  as  complete  asepsis,  is  essential 
for  the  successful  performance  of  surgical  pro- 
cedures. Beta-eucaine  is  a  stable  compound.  Its 
solutions  keep  for  an  indefinite  time  without  un- 
dergoing decomposition.  The  solution  of  beta- 
eucaine  can  be  frequently  boiled  without  injury 
and  without  losing  its  anesthetic  properties.  It  has 
no  action  on  the  pupil,  on  accommodation,  or  on 
eye  tension.  One  reason  for  the  similarity  of 
analgetic  action  existing  between  eucaine  and 
cocaine  is,  according  to  Braun,  that  their  osmotic 
tension  is  the  same.  The  anesthesia  produced  by 
it  is  of  longer  induction  and  of  shorter  duration 
than  that  induced  by  cocaine.  "Being  3.75  times 
less  toxic  than  cocaine,  it  has  the  advantages  in 
stomatology  that  the  patient  need  not  lie  down 
during  the  operation;  that  he  can  go  away  at  once; 
and  that  none  of  the  difficulties  that  sometimes 
follow  the  use  of  cocaine  occur.  It  should  there- 
fore, in  this  department,  be  preferred  to  the  latter 
drug.  In  general  surgery  of  the  minor  kind, 
cocaine  is  to  be  preferred  because  it  is  safe  when 
prudently  administered,  and  is  free  from  some  of 
the  inconveniences  of  eucaine."  (Chapiro.)  The 
following  solutions  are  used: 

For  o|)hthalmic  purposes,  in  2%  to  3%.  (Most 
Chicago  oculists  prefer  cocaine  for  ophthalmic 
work.) 

For  dental  and  general  surgical  use,  2%  to  3% 


CHOICE   OF   LOCAL   ANESTHETIC. 


115 


solution.    Many  surgeons,  however,  use  a  5%  solu- 
tion for  hypodermic  use. 

For  examinations,  as  of  the  larynx,  of  the 
urethra  or  of  the  bladder,  1%  to  3%  solution. 

For  operations  in  the  nasal  fossae,  in  the  naso- 
pharynx, and  in  the  larynx,  a  4%  to  5%  solu- 
tion is  required  to  secure  satisfactory  anesthesia. 

For  the  alleviation  of  painful  deglutition  asso- 
ciated with  laryngeal  tuberculosis,  a  5%  spray  of 
Beta-Eucaine  can  be  used  in  the  larynx. 

For  infiltration  anesthesia,  Braun's  formula  is 
used.     It  admits  of  sterilization  by  boiling. 

Beta-Eucaine 0.1 

Sodium  Chloride 0.8 

Aquae  distillatae 100 . 

For  the  production  of  beta-eucaine  anesthesia, 
the  technique  employed  in  the  induction  of  cocaine 
local  anesthesia  meets  the  indications.  If  Braun's 
formula  is  used  to  induce  infiltration  anesthesia, 
employ  the  technique  that  I  follow  with  Schleich's 
solutions. 

The  following  is  quoted  from  Gerald  Dalton, 
and  will  give  some  idea  of  the  applications  of  beta- 
eucaine. 

"Anesthetizing  the  urethra  in  conditions  where 
the  passing  of  sounds,  catheters,  urethroscopic 
tubes,  etc.,  cause  more  pain  than  is  desirable.  The 
anterior  urethra  is  injected  with  1  dram  of  a 
3%  solution  of  beta-eucaine,  injected  by  means 


116    '?5^  GENERAL    AND    LOCAL    ANESTHESIA.  i 


of  an  ordinary  small  urethral  syringe^  the  glans 
penis  being  held  tightly  np  against  the  nozzle  so 
that  no  fluid  may  run  out  of  the  urethra.  The 
solution  is  kept  in  the  passage  five  to  ten  minutes; 
when  it  is  let  out,  the  anterior  urethra  will  be 
found  anesthetized  quite  sufficiently  to  permit  the 
passage  of  even  large  instruments  without  pain. 
If  it  is  required  to  introduce  instruments  into  the 
prostatic  portion  or  bladder,  after  allowing  the 
solution  to  run  out  of  the  anterior  urethra,  20' 
minims  of  a  3%  solution  should  be  injected  into 
the  prostatic  urethra  by  the  prostatic  instillator, 
and  the  instrument  withdrawn;  the  solution  being 
retained  by  the  compressor  urethras  muscles.  A 
pause  of  four  to  five  minutes  more  will  be  neces- 
sary, when  the  posterior  urethra  will  also  be  found 
insensitive  to  pain.  The  anesthesia  lasts  for  a 
period  varying  from  five  to  twenty  minutes. 

"Circumcision. — The  foreskin  and  glans  having 
been  cleansed  in  the  ordinary  way,  1  dram  of  a 
5%  solution  of  eucaine  is  injected  with  the  ordin- 
ary urethral  syringe  under  the  foreskin,  which  is 
drawn  well  forward  (when  possible);  the  syringe 
is  slipped  out,  the  solution  being  kept  in  between 
the  glans  penis  and  prepuce  by  tightly  holding  the 
end  of  the  latter  (this  can  usually  be  done  by  the 
patient  himself).  A  hypodermic  syringe  is  then 
charged  with  a  3%  normal  saline  solution  of 
eucaine.     Commencing    near   the   frenum,    small 


CIRCUMCISION  BY   LOCAL   ANESTHETIC.  117 

blebs  of  solution  are  made  just  under  the  skin^ 
each  bleb,  of  about  2  minims,  touching  its  neigh- 
bor. A  ring  is  thus  made  under  the  line  of  incision. 
When  this  is  finished,  about  six  to  eight  deep  in- 
jections are  made  into  the  subcutaneous  tissue, 
with  perhaps  one  or  two  extra  ones  near  the 
frenum.  The  solution  retained  under  the  foreskin 
is  now  allowed  to  run  ont,  the  parts  are  cleaned, 
and  the  operation  is  begun  at  once.  Bichloride  of 
mercury  solution  should  not  be  used,  but  carbolic 
acid,  or  chinosol,  etc.,  may  be  employed.  The 
operation  will  probably  not  be  absolutely  painless; 
but  the  pain  will  be  so  slight  that  it  is  perfectly 
bearable  even  by  a  highly  nervous  patient. 

"Buboes. — In  opening  and  curetting  suppurating 
buboes  in  the  groin  or  elsewhere,  the  parts  having 
been  cleaned,  a  3%  solution  is  injected  under  the 
skin  in  the  line  of  incision,  as  for  circumcision; 

five  or  six  deeper  injections  are  made  into  the 
tissues  beneath.  Both  in  this  operation  and  in 
the  one  for  circumcision,  40  to  80  minims  may  be 
used.  The  incision  is  made  at  once;  it  is  not 
necessary  to  wait  ten  minutes,  as  sometimes  stated, 
after  the  hypodermic  injection;  since  absorption 
from  a  mucous  membrane  by  contact  takes  place 
less  rapidly.  After  evacuating  the  pus,  a  5%  solu- 
tion is  poured  into  the  wound,  or  pledgets  of 
cotton  soaked  in  solution  are  packed  into  the 
cavity;    a  delay  of  a  few  minutes  is  made  when 


118  GENERAL    AND    LOCAL    ANESTHESIA. 

curetting  may  be  lightly  performed  painlessly. 
One  dram  of  solution  may  be  used  for  this  with 
safety.  Occasionally  the  skin  over  the  bubo  is  so 
inflamed  and  tender  that  even  the  prick  of  the 
needle  is  dreaded  by  some  patients.  This  may  be 
obviated  by  previously  spraying  with  ethyl 
chloride. 

"Hydrocele. — The  hydrocele  is  tapped,  and  the 
fluid  withdrawn.  One  drachm  of  a  3%  solution 
is  injected  into  the  sac  through  the  trocar.  Iodine 
may  then  be  injected  in  the  usual  way.  The 
patient  only  complains  of  a  "warm  sensation," 
instead  of  severe  pain  usually  experienced.  There 
is  no  after-pain.^" 

(c)  Guaiacol  dissolved  in  olive  oil  has  been  used 
as  a  local  anesthetic.  Guaiacol  is  intensely  irri- 
tating and  is  insoluble  in  water.  It  has  not  met 
with  general  favor.  It  is  still  used  in  selected  cases 
by  its  introducer^  Lucas-Championniere,  and  his 
personal  admirers;  it  does  not  produce  anesthesia 
as  rapidly  as  cocaine  or  the  infiltration  method; 
it  can,  by  its  vaso-constrictive  action,  cause 
sphacelus;  it  does  not  always  procure  anesthesia; 
there  is  much  smarting  at  the  periphery  of  the 
area  into  which  the  fluid  is  injected,  and  this 
smarting  lasts  longer  than  the  anesthesia. 

(d)  Carbolic  acid  is  employed  as  a  local  anes- 
thetic. It  exerts  a  destructive  and  caustic  action 
on  the  tissues.    It  does  not  penetrate  deeply. 


ANTIPYRIN   AS   A   LOCAL   ANESTHETIC.  119 

Antipyrin  is  valuable  to  obtain  anesthesia  of  the 
urinary  bladder.    Its  anesthetic  power  is  less  than 
that  of  cocaine,  but  it  has  the  advantage  of  being 
less  toxic.     Surgical  local  anesthesia  can  be  in- 
duced by  the  aforenamed  and  other  less  valuable 
agents.     It  is  neither  necessary  nor  practical  for 
the  medical  practitioner  to  have  a  thorough  and 
complete  knowledge  of  every  agent  that  can  induce 
local  anesthesia.     It  is  far  wiser  and  of  far  more 
utility  for  him  to  confine  himself  to  the  use  of 
those  local  anesthetic  agents,  the  value  of  which 
is  universally  acknowledged  and  to  master  thor- 
oughly   the    technique    of    their    administration. 
Experimentation  is  legitimate  and  commendable 
when  carried  on  in  laboratories  and  in  large  public 
hospitals  by  experienced  men.     Private  patients, 
however,  pay  to  be  healed,  not  to  be  immolated 
on  the  altar  of  science,  hence  the  busy  general 
practitioner  must  accept  the  teachings  of,  and 
adopt  the  methods  sanctioned  and  employed  by 
the  specialist. 

Local  anesthesia  is  nowadays  generally  induced 
by  one  of  the  following  methods: 

(1)  Eefrigeration— (a)  cold;  (b)  evaporation  of 
ether;   (c)  ethyl  chloride,  etc.,  etc. 

(2)  The  use  of  Cocaine  and  Eucaine  B. — (a) 
applied  superficially  to  mucous  membranes;  (b) 
injected  subcutaneously;  (c)  with  the  cataphoric 
action  of  the  galvanic  current.     Cocaine  is  the 


120  GENERAL    AND    LOCAL    ANESTHESIA. 

most  effective  of  our  local  aneshtetic  agents.  Its 
toxicity  is  its  drawback. 

(3)  The  infiltration  method. — The  principle 
being  to  infiltrate  the  entire  field  of  operation  with 
fluid  as  indifferent  as  possible  to  the  organism. 
To  obtain  a  complete  anesthesia  with  an  infiltrat- 
ing fluid, the  entire  area  must  be  tensely  infiltrated. 
The  effect  appears  immediately  after  the  injection. 

In  using  cocaine,  eucaine,  and  the  infiltration 
method  of  anesthesia,  an  elastic  bandage  should  be 
applied  whenever  possible,  even  about  the  scalp. 
Care  should  be  taken  not  to  apply  it  too  tightly, 
and  also  that  it  be  loosened  gradually  after  the 
operation  is  well  over. 

Local  anesthetics  in  the  present  state  of  our 
knowledge  can  not  entirely  displace  general 
anesthetics.  General  surgical  anesthesia  and  local 
surgical  anesthesia  have  each  their  respective 
indications  and  limitations,  each  their  respective 
advantages  and  disadvantages. 

ADVANTAGES  OF  LOCAL  OVER  GENERAL  ANES- 
THETICS. 

The  advantages  which  local  anesthetics  possess 
over  general  anesthetics  are: 

1.  Minor  operations  with  local  anesthesia  can 
be  performed  without  assistants.  This  is  a  matter 
of  importance  to  the  country  practitioner  who  can 
not  as  easily  obtain  skilled  assistants  as  his  city 
brethren.     This  is  also  important  when  there  are 


ADVANTAGES   OF   LOCAL   ANESTHETIC.  121 

no  means  with  which  to  compensate  an  assistant. 
The  giving  of  a  general  anesthetic  involves  a  great 
expenditure  of  energy  and  the  assuming  of  a  great 
responsibility,  and  it  is  nnkind  to  ask  a  fellow- 
practitioner  to  give  a  general  anesthetic  for  a  mere 
"thank  you." 

2.  Greater  rapidity  of  action.  Their  use  does 
not  entail  the  loss  of  time  incident  to  putting 
patient  under  the  influence  of  a  general  anesthetic. 

3.  Headache,  nausea,  vomiting,  etc.,  do  not 
follow  their  use.  Annoying  after-effects  are 
exceptional. 

4.  Their  use  does  not  give  rise  to  any  serious 
after  effects.  Nephritis,  pulmonary  inflammations, 
paralysis  and  other  pathological  states  have 
occurred  consequent  to  the  inhalation  of  general 
anesthetics. 

5.  General  anesthesia  is  always  accompanied 
by  more  or  less  depression  or  shock.  After  minor 
operations,  under  general  anesthesia,  the  shock  or 
depression  is  often  due  to  the  ether  or  chloroform 
administered.  General  anesthetics  are  depressants. 
In  debilitated  patients,  they  lower  the  general 
vitality,  they  lower  the  patient's  natural  resistance 
to  disease.  In  laryngeal  diphtheria  necessitating 
the  performance  of  tracheotomy,  avoid  the  depres- 
sing effects  of  general  anesthetics  by  the  use  of 
local  anesthesia.  "Extreme  prostration  and 
asphyxia  from  diphtheritic  poisoning  are  absolute 


123  GENERAL    AND    LOCAL    ANESTHESIA. 

contra-indications  to  the  use  of  Chloroform  in 
tracheotomy/^  (Geffrier.)  Fraenkel  reports 
twenty-three  cases  of  tracheotomies  performed 
successfully  under  cocaine  anesthesia.  Lennox 
Brown  reports  forty. 

In  Prof.  SchleicVs  elinic,  infiltration  anesthesia 
has  been  used  with  success  in  tracheotomies  per- 
formed for  the  relief  of  dyspnea  due  to  chronic 
stenosis  and  to  acute  diphtheritic  stenosis. 

6.  There  is  a  mortality  inherent  to  the  use  of 
general  surgical  anesthesia.  The  dangers  of  gen- 
eral anesthesia  are,  however,  dependent  more  on 
the  experience  and  competence  of  the  anesthetist 
than  on  the  drug  itself.  Skilled  anesthetists  rarely 
have  fatalities.  Lawrie  of  India  reports  45,000 
chloroformizations  with  no  death.  The  mortality 
of  local  anesthetics,  when  cautiously  used,  is  prac- 
tically nil.  They  can  be  used  when  the  patient  is 
too  ill  to  take  a  general  anesthetic  with  safety.  In 
cases  where  there  are  grave  objections  to  the 
employment  of  general  anesthesia,  major  opera- 
tions can  be  performed  under  local  anesthesia. 
Amputation  of  the  thigh  has  been  successfully 
done  under  cocaine  anesthesia. 

With  general  anesthesia  the  operator  has  to 
work  in  a  constrained  position.  This  is  not  the 
case  with  local  anesthesia. 

8.  Local  anesthetics  do  away  with  the  appre- 
hension and  fear  which  most  people  have  against 


ADVANTAGES    OF    LOCAL   ANESTHESIA.  123 

being  put  to  sleep  with  a  general  anesthetic.  Their 
use  meets  less  objection  on  the  part  of  patients. 
Consent  to  their  use  is  more  easily  obtained. 
Hence^  surgical  interventions  can  be  more  timely, 
more  opportune.  Patients  are  not  so  afraid  of 
local  anesthesia  as  they  are  of  general  anesthesia. 
While  they  are  thinking  over  the  advisability  of 
taking  a  general  anesthetic,  the  pathological 
processes  progress. 

9.  The  technique  of  their  administration  is 
comparatively  simple.  No  previous  preparation  of 
the  patient  is  required.  In  operations  about  the 
face,  throat  and  nose,  any  apparatus  used  (Souch- 
on's  excepted)  to  produce  general  anesthesia 
embarrasses  the  operator,  interferes  with  his 
operative  manipulations. 

10.  The  operator  does  not  lose  patient's  co- 
operation and  guidance.  The  patient  remaining 
conscious,  operations  about  the  oral  cavity  under 
local  anesthesia  are  not  attended  with  the  danger 
of  deglutition  of  blood,  of  aspiration  of  blood  and 
foreign  bodies  as  teeth,  etc.,  into  the  respiratory 
passages.  The  patient  can  be  of  aid  to  the  surgeon 
by  opening  his  mouth,  thus  doing  away  with  the 
use  of  the  mouth  gag  to  maintain  jaws  apart,  can 
expectorate  any  blood  accumulating  in  mouth. 
The  patient  being  conscious,  there  is  no  danger  of 
the  tongue  falling  backward,  occluding  the  glottis 
and  causing  asphyxia,  no  danger  of  a  tooth  or 


124  GENERAL    AND    LOCAL    ANESTHESIA. 

foreign  body  being  swallowed.  In  operations  on 
hands  or  feet  in  which  cut  tendons  have  been 
sntnred,  when  one  wishes  to  find  ont  whether  the 
ends  have  been  correctly  adjusted,  voluntary 
motion  supplies  at  once  the  physiological  test. 

11.  Local  anesthetics  do  away  with  the  retching 
and  vomiting  that  so  often  accompany  the  induc- 
tion of  general  anesthesia.  This  retching  and 
vomiting  are  especially  objectionable  in  operations 
about  the  face,  mouth,  throat  and  eyes. 

12.  Local  anesthetics  are  more  agreeable  to  the 
patient,  are  safer  than  general  anesthetics.  The 
comfort  and  safety  of  the  patient  should  ever  be 
present  to  the  physician's  mind.  Hence,  we  always 
employ  local  anesthetics  instead  of  general  anes- 
thetics when  the  temperament  of  the  patient  and 
the  nature  of  the  operation  render  their  use 
practicable. 

WHEN"     NOT     TO     BE     USED. 

Local  anesthetics  must  not  be  resorted  to  in  the 
presence  of  insurmountable  fear  felt  by  the 
patient;  of  hysteria;  or  against  his  personally  ex- 
pressed wish  to  take  a  general  anesthetic;  when 
they  would  fail  to  secure  a  sufficiently  deep  anes- 
thesia; when,  in  operations  requiring  exposure,  a 
general  anesthetic  might  be  preferred  on  sentiment- 
al grounds;  where  muscular  relaxation  is  required, 
as  in  the  reduction  of  fractures  and  of  dislocations, 
as  in  intra-abdominal  operations;  when  very  exten- 


WHEN    NOT   TO    BE   USED,  125 

sive  dissection  is  necessary,  as  in  the  separation  of 
abdominal  adhesions  in  surgery.  (Abbe.)  It  must 
not  be  resorted  to  in  operations  where  one  does 
not  know  beforehand  how  extensive  the  necessary 
operative  procedures  will  be.  Many  a  surgeon  has 
been  obliged  to  finish  an  unexpectedly  extensive 
dissection  upon  a  groaning,  screaming  patient, 
because  "he  had  already  reached  the  limit  of  safety 
in  the  use  of  his  local  anesthetic  agent,  or  because 
he  found  a  further  extension  of  the  local  anes- 
thesia impracticable  for  one  reason  or  another. 

IS'either  should  they  be  resorted  to  in  the  case  of 
very  nervous  individuals  or  in  children,  because 
they  are  liable  to  become  unruly  on  seeing  the 
knife,  making  local  anesthesia  often  insufficient 
and  very  unsatisfactory.  "Children,  for  instance, 
appear  to  be  unsuitable  subjects  for  this  procedure. 
The  mere  sight  of  the  surgical  preparations  for 
operation  frightens  them,  and  their  unstable  emo- 
tional condition  is  upset  by  the  slightest  pain. 
Very  timid  adults  for  the  same  reason  are  also 
better  with  general  anesthesia.^'  (Barker.)  Nor 
should  they  be  used  in  major  operations  attended 
by  much  hemorrhage,  since  the  consciousness  of 
the  patient  in  these  conditions  is  annoying  to  the 
operator,  nor  when  the  employment  of  a  local 
anesthetic  would  impair  the  vitality  of  the  tissues. 

Local  anesthetics  will  be  found  very  serviceable 
and  preferable  to  general  narcosis  in  all  operations 


126         GENERAL  AND  LOCAL  ANESTHESIA. 

simple  in  technique  which  do  not  take  np  much 
time  and  where  every  step  is  well  known.  Opera- 
tions such  as  the  following  come  within  the 
domain  of  local  anesthesia: 

Abdominal  and  thoracic  puncture;  incision  and 
evacuation  of  abscesses  when  located  near  the  sur- 
face; operations  on  felons^  carbuncles,  naevi, 
sebaceous  cysts;  lipomata;  adenomata  of  breast 
when  near  surface;  circumcisions;  castrations; 
and  many  operations  in  ophthalmology,  larjm- 
gology  and  rhinology. 

HOW     TO     PROCEED. 

It  is  well,  however,  to  bear  in  mind  that  the 
anesthesia  obtained  by  the  use  of  local  anesthetics 
is  not  as  complete  as  that  obtained  by  the  use  of 
general  anesthetics.  Consciousness  being  present, 
the  perception  of  pain  is  not  as  completely  abol- 
ished as  with  general  anesthetics.  Many  individ- 
uals, however,  will  prefer  to  endure  a  slight 
amount  of  pain  rather  than  be  put  to  sleep. 

The  induction  of  local  surgical  anesthesia  should 
only  be  practiced  by  qualified  and  responsible  per- 
sons, that  is,  by  dentists  and  by  physicians. 
Irrational  employment  of  local  anesthetics  leads  to 
deleterious  results.  The  toxicity  of  the  agents 
employed  and  the  serious  consequences  that  can 
follow  their  unscientific  use  amply  justify  the 
dictum  at  the  beginning  of  this  paragraph. 


ANESTHESIA    BY    REFRIGERATION,  137 

When  about  to  induce  local  anesthesia,  and  to 
operate  under  it^  whatever  may  be  the  agent  used, 
cover  the  patient^s  face  with  a  light  fabric  so  as 
to  completely  close  off  the  field  of  operation  from 
his  observation.  The  sight  of  surgical  instruments, 
of  the  operator's  movements,  of  blood,  will  in  some 
patients  induce  syncope.  The  patient  seeing  or 
being  aware  that  an  operation  is  being  done  upon 
him,  the  apprehension  which  is  so  commonly  felt 
that  pain  will  be  experienced,  in  many  cases,  pro- 
duce faintness  and  in  some  instances  fatal  syncope. 

i^lways  tell  the  patient  that  there  will  be  a 
slight  amount  of  pain;  he  will  then  not  be  sur- 
prised is  he  experiences  a  little  pain  and,  being 
forewarned,  will  not  become  alarmed.  Section  or 
rough  manipulation  of  muscle  tissue  causes  dull 
pain  of  an  aching  character  which  can  easily  be 
endured.  (Lilienthal.)  Section  or  manipulation 
of  tendons  is  not  felt.  Manipulation  of  nerves 
causes  a  pain  which  is  acute,  if  nerve  is  grasped 
with  clamp  or  caught  in  a  ligature.  (Lilienthal.) 
Ligature  of  arteries  is  painful.  Vaso-motor  nerves 
are  sensitive.    (Wyeth.) 

ANESTHESIA     BY     REFKIGERATION. 

Cold  benumbs  the  nerve-endings  or  trunks. 
The  freezing  methods  are  of  limited  application 
because  (a)  cold  not  penetrating  beyond  a  very 
shallow  depth,  this  method  of  anesthesia  suffices 


128  GENERAL    AND    LOCAL    ANESTHESIA^- 

only  for  short  surface  operations;  (b)  they  can 
be  applied  only  to  limited  areas;  there  is  danger 
of  gangrene  of  the  frozen  tissues;  (c)  freezing 
retards  healing;  (d)  anesthesia  produced  by  the 
refrigerating  methods  is  evanescent;  its  induction 
is  attended  with  pain^  especially  in  inflamed  parts; 
the  pain  following  its  disappearance  is  at  times 
very  severe;  (e)  freezing  substances  harden  the 
tissue  and  alter  the  appearances  of  cut  surfaces, 
making  it  difficult  to  differentiate  between  normal 
and  pathological  states  of  tissues.  (Lilienthal.) 
(f)  Their  use  in  certain  tissues,  as  on  the  scrotum, 
may  produce  a  slough. 

Chopped  ice  and  salt  are  used.  Dr.  Lemke  uses 
these  to  anesthetize  the  site  of  insertion  of  the 
canula,  previous  to  injecting  nitrogen  gas  in  tuber- 
cular pulmonary  cavities.  Eub  over  the  part  to  be 
incised  a  small  muslin  bag  containing  some  ice 
pounded  very  fine,  and  salt.  This  is  to  be  kept 
up  for  two  or  three  minutes,  or  until  the  skin  is 
blanched. 

Sprays  of  solutions,  of  which  the  following  is 
a  fair  example,  are  extensively  employed: 

Chloroform parts  10 

Ether parts  15 

'Menthol part       1 

This  solution  quite  freezes  the  part  in  about  a 
minute.  The  skin  becomes  white  and  hard.  The 
freezing  process  must  not  be  carried  too  far,  other- 


ETHYL   CHLORIDE. 


129 


wise  a  slough  is  apt  to  ensue.  The  anesthesia 
produced  by  this  spray  lasts  from  two  to  six 
minutes.  The  solution  and  all  others  containing 
ether^  must  not  be  used  in  operations  about  the 
eye.  Ether  vapor  irritates  the  cornea  and  con- 
junctiva. 

Ethyl  Chloride  (that  of  French  manufacture  is 
the  best)  is  of  use  to  anesthetize  very  superficial 
parts,  as  when  a  mere  incision  is  to  be  made  in 
the  skin.  It  is  useful  in  the  opening  of  abscesses 
and  felons.  It  is  useful  in  the  removal  of  warts, 
both  simple  and  venereal,  and  in  the  extraction  of 
foreign  bodies.  If  too  much  pressure  is  not  made, 
that  is,  if  the  knife  is  sharp,  operations  under 
ethyl-chloride  anesthesia  are  practically  painless. 
It  is  usually  dispensed  in  large  glass  tubes,  Avhich 
contain  enough  ethyl  chloride  to  produce  anes- 
thesia in  at  least  a  dozen  cases.  The  heat  of  the 
hand  causes  the  liquefied  gas  to  issue  in  spray 
form.  In  order  to  produce  local  anesthesia,  the 
bulb  of  the  tube  is  held  in  the  palm  of  the 
surgeon's  hand.  The  cap  is  unscrewed  and  the  jet 
of  spray  is  directed  to  the  spot  that  is  to  be 
anesthetized.  Hold  tube  at  a  distance  of  from 
six  to  ten  inches  from  the  part  to  be  anesthetized. 
The  part  soon  becomes  frozen  and  ready  for  oper- 
ation. Do  not  operate  before  the  part  has  assumed 
a  parchment-white  color.  This  white  color  is  in- 
dicative of  local  refrigeration,  is  indicative  of  loss 


130  GENERAL    AND     LOCAL    ANESTHESIA. 

of  dermal  sensation  in  frozen  area.  It  is  a  good 
rapid  local  anesthetic,  having  no  influence  on  the 
sensory  nerve  centers  in  the  brain.  Anesthesia  is 
induced  in  less  than  a  minute  and  lasts  about  two 
minutes.  This  substance  is  highly  inflammable, 
and  when  it  is  used,  operations  must  be  done  at 
a  good  distance  from  gas  or  other  flame.  The 
exact  limits  of  the  operations  must  be  determined 
beforehand,  because  the  ethyl  chloride  hardens  the 
skin.  In  many  operations  constriction  of  a  mem- 
ber may  be  practiced  before  applying  the  spray. 
This,  by  limitation  of  the  warm  blood  supply,  will 
efl^ect  a  more  rapid  and  lasting  anesthesia.  After 
using  the  spray,  the  cap  must  be  screwed  on 
tightly,  as  the  extreme  volatility  of  this  substance 
will  cause  its  escape  from  the  tube  if  the  screw 
cap  is  loosely  adjusted. 

Previous  to  using  the  ethyl  chloride  spray,  the 
field  of  operation  must  be  sterilized.  The  bulb  of 
ethyl  chloride  must  be  held  with  sterile  gauze  so 
that  the  surgeon  will  not  contaminate  his  hands. 

COCAIlSrE. 

Cocaine  is  to  the  rhinologist,  laryngologist  and 
ophthalmologist  what  chloroform  and  ether  are  to 
the  general  surgeon.  For  the  ophthalmologist, 
cocaine  meets  every  requirement  that  could  rea- 
sonably be  expected  from  a  local  anesthetic.  It 
has  caused  a  few  deaths.     So  has  opium,  so  has 


COCAINE,    ITS    PROPERTIES.  1^1 

belladonna,  and  so  have  many  other  valnable  medic- 
inal agents.  These^  few  fatalities  should  not  lead 
ns  to  abandon  the  nse  of  cocaine,  but  should  stim- 
ulate us  to  discover  and  observe  methods  of  admin- 
istration that  do  away  with  some  of  the  uncer- 
tainties attending  its  use.  Careful  attention  to 
the  teachings  of  experimental  therapeutics  and 
close  observation  of  the  methods  practiced  by 
eminent  clinicians,  minimize  the  dangers  incident 
to  therapeutic  procedures  and  enhance  their  value 
to  humanity.  Cocaine  is  an  agent  of  great  power 
and  usefulness,  but  it  must  be  used  with  caution. 
In  the  absence  of  positive  contra-indications  to 
the  use  of  general  anesthesia,  it  should  not  be  used 
in  irregular  and  prolonged  operations,  as  in  abdom- 
inal surgery.  The  quantity  required  to  maintain 
prolonged  anesthesia  is  toxic.  Neither  should  it 
be  used  in  individuals  showing  organic  disease  of 
the  brain,  heart,  lungs  or  kidneys,  when  local 
anesthesia  by  refrigeration,  by  infiltration  or  by 
the  use  of  such  agents  as  antipyrin,  orthoform  or 
strophantheine  meets  the  indications. 

PROPEKTIES     OF     COCAINE. 

Cocaine  paralyzes  the  terminal  filaments  of  the 
peripheral  sensory  nerves  when  brought  in  contact 
with  them.  Its  use  as  a  local  anesthetic  is  based 
upon  this  property.  The  less  vascular  the  part  the 
more  intense  its  action.     It  possesses  remarkable 


133  GENERAL    AND    LOCAL   ANESTHESIA. 

anesthetic  properties  upon  mucous  membranes. 
All  mucous  membranes  are  amenable  to  its  anes- 
thetic properties.  A  canal  lined  with  mucous 
membrane  may  be  rendered  insensitive  by  inject- 
ing into  it  a  small  amount  of  cocaine  solution. 
The  conjunctival;,  the  labial^  the  nasal,  the  pharyn- 
geal, the  gastric,  the  urethral,  the  vesical,  the 
rectal^  the  vaginal  and  the  uterine  mucous  memx- 
branes  are  all  anesthetized  by  the  application  of 
cocaine  to  them.  The  application  to  any  of  these 
membranes  of  swabs  of  cotton  saturated  with  a 
solution  of  cocaine  is  followed  by  insensibility  in 
from  three  to  five  minutes.  The  cocaine  solution 
can  be  brushed  upon  the  field  of  operation.  This 
loss  of  sensation  continues  for  from  fifteen  to 
twenty  minutes.  The  influence  of  cocaine  solu- 
tions on  mucous  membranes  depends  entirely  upon 
the  strength  of  the  solution,  the  frequency  of  the 
applications  and  the  time  that  has  elapsed  from 
the  time  of  first  application.  A  2%  solution 
is  almost  always  sufficiently  strong  to  obtain  anes- 
thesia of  mucous  membranes  for  minor  operations. 
The  statement  made  by  some  that  a  2%  solution 
is  more  effective  than  a  stronger  solution  is  erro- 
neous. To  secure  anesthesia  in  throat,  nose, 
larynx,  do  not  use  the  spray.  Spraying,  be  it  ever 
so  skillfully  done,  will  not  prove  as  satisfactory  as 
a  properly  shaped  and  carefully  applied  cotton 
pledget. 


COCAINE,    ITS    PROPERTIES. 


133 


Applied  to  the  unbroken  skin,  cocaine  does  not 
anesthetize  it.    To  anesthetize  the  skin  the  cocaine 
solution  must  be  injected  in  the  dermal  tissues; 
that  is,  in  the  skin  and  not  beneath  it.    Injections 
must  be  intradermic  and  not  hypodermic.    There 
is  a  difference  in  the  susceptibility  of  patients  to 
cocaine,  also  a  difference  in  the  susceptibility  of 
the  same  patient  on  different  occasions.     There 
are  individual  idiosyncrasies.     Children  appear  to 
come  more  quickly  under  the  influence  of  the  drug 
than  adults.     The  application  of  cocaine  to  the 
conjunctival,    vaginal   and   rectal   mucous   mem- 
branes is  almost  never  followed  by  alarming  symp- 
toms.    Serious  accidents  have  followed,  however, 
its  application  to  the  urethral  mucous  membrane. 
Its  subcutaneous  use  has  given  rise  to  a  few  acci- 
dents.    In  vascular  regions,  such  as  face,  scalp, 
nasal  fossa?  and  mouth,  large  quantities  of  cocaine 
solution  must  not  be  used.    Eeclus  collected  from 
the  medical  literature,  and  analyzed,  sixteen  deaths 
due  to  cocaine  anesthesia.    He  says  that  all  these 
deaths  were  due  to  one  or  more  of  the  following 
conditions: 

(1)  The  use  of  too  strong  solutions. 

(2)  Sudden  emptying  of  large  quantities  of  the 
drug  into  the  general  circulation,  either  by  punc- 
ture of  a  vein  or  injection  into  areas  vascular, 
by  virtue  of  the  presence  of  an  inflammation  or 
naturally  so,  as  is  the  case  with  the  head. 


134  GENERAL    AND    LOCAL    ANESTHESIA. 

(3)  Operating  in  the  erect  position  was  a  factor 
in  all  the  cases. 

"The  healing  process  is  not  impaired  by  the  use 
of  cocaine.*^  (Lndwig  Pernice.)  "In  my  experi- 
ence^ wounds  made  nnder  the  influence  of  cocaine 
have  invariably  healed  well."     (\Y.  Moore.) 

These  opinions  are  in  accord  with  the  experience 
of  all  those  that  have  used  cocaine  extensively. 

The  application  of  cocaine  to  mncons  surfaces 
is  attended  by  a  weakening  of  the  reflexes,  so  that 
parts  can  be  handled  that  without  the  influence 
of  cocaine  conld  not  be  handled.  Insensibility 
follows  its  application  to  mncons  membranes  in 
from  three  to  five  minutes,  and  lasts  about  ten 
minutes. 

For  cocaine  anesthesia  use  the  hydrochlorate  of 
cocaine,  the  alkaloid  itself  is  very  insoluble  in 
water;  other  preparations  do  not  possess  the  same 
anesthetic  properties.  (Franz  Fux.)  Cocaine  phe- 
nate,  being  insoluble  in  water,  is  unsuited  for 
hypodermic  use.  In  making  ointments,  cocaine, 
the  alkaloid  is  used,  as  it  is  soluble  in  fats,  whereas 
its  salts  are  not. 

COCAINE     IX     OPHTHALMOLOGY. 

Cocaine  is  of  especial  service  to  the  ophthalmol- 
ogist, as  it  does  not  cause  phenomena  of  irritation. 
(Koller.) 

In  oiDhthalmology  it  is  used  to  control  pain  in 


COCAINE   IN   OPHTHALMOLOGY.  135 

the  eye,  in  the  removal  of  foreign  bodies  present 
in  the  conjunctival  sac  or  imbedded  in  the  cornea, 
and  in  such  operations  as  iridectomy,  cataract 
removal,  sclerotomy,  extirpation  of  eyeball,  cure  of 
strabismus,  etc.  Slitting  of  canaliculi  and  other 
operations  on  lachrymal  ducts  are,  with  its  use, 
done  painlessly.  The  same  applies  to  ablation  of 
small  tumors,  as  cysts,  to  removal  of  pterygium, 
etc.  Cocaine  does  not  possess  the  disadvantage  of 
producing  the  enormous  engorgement  of  the 
ocular  vessels  that  ether  does.  An  objection  to  the 
use  of  general  anesthesia  in  ophthalmology  is  the 
possibility  of  vomiting  which  may  occur  during 
or  after  the  administration  of  a  general  anesthetic. 
This  is  always  dangerous  aftej  a  cataract  operation. 
Vomiting  by  causing  a  too  rapid  escape  of  the 
aqueous  humor  may  cause  extensive  prolapse  of 
iris,  subluxation  of  lens,  prolapse  of  the  vitreous 
humor,  intraocular  hemorrhage.  The  use  of 
cocaine  anesthesia  eliminates  the  danger  of  vomit- 
ing. Under  local  anesthesia,  the  23atient  can 
direct  the  movements  of  his  eyes  according  to  the 
necessities  of  the  operation.  This  is  impossible 
under  general  anesthesia. 

Holtz  (Chicago)  uses  a  2%  cocaine  solution  to 
anesthetize  corneal  ulcers  previous  to  cauterizing 
them.  For  most  operations,  ophthalmologists 
employ  solutions  varying  from  3%  to  5%  in 
strength.    A  few  drops  of  this  solution  are  injected 


136  GENERAL    AND    LOCAL    ANESTHESIA. 

several  times  into  the  conjunctival  sac,  at  intervals 
of  few  minutes.  For  enucleation  of  the  eyeball, 
J.  A.  White  says:  "A  solution  of  from  10%  to 
20%  is  required  to  deaden  the  sensibility  of  deep 
tissues  surrounding  the  optic  and  ciliary  nerves.'' 
About  five  minutes  before  the  division  of  these 
deep  tissues  inject  in  them,  by  means  of  a  syringe 
with  a  long  canula,five  min.of  the  cocaine  solution. 
Cocaine  solutions  can  be  injected  into  the  sub- 
stance of  the  eyeball  if  necessary.  If  the  perform- 
ance of  the  operation  is  delayed  ten  or  fifteen 
minutes  after  the  first  instillation,  for  the  drug 
to  pass  through  the  cornea,  the  iris  will  be  com- 
pletely anesthetized  and  iridectomy  can  be  per- 
formed without  pain."  (A.  Duane.)  Solutions  of 
atropine,  eserine,  or  cocaine,  when  applied  to  the 
surface  of  the  conjunctiva,  by  a  process  of  endos- 
mosis,  soak  through  the  cornea  and  become  dif- 
fused in  the  aqueous  humor;  they  are  thus  brought 
in  actual  contact  with  the  iris. 

In  making  subconjunctival  injections  of  cocaine, 
the  episclera  must  not  be  wounded.  A  1%  solution 
is  a  safe  solution  for  that  purpose. 

COCAINE  ABOUT  THE  MOUTH,  NOSE,  ETC. 

An  objection  to  the  use  of  general  anesthetics 
in  operations  about  the  mouth,  nose,  larynx,  is 
that  voluntary  cough  can  not  take  place  until  the 
patient  has  recovered  from  the  effect  of  the  general 


',.  -•  COCAINE    IN    MOUTH    AND    NOSE,  137 

anesthetic.  During  this  period  accumulation  of 
blood  in  the  main  air-passages  may  cause  asphyxia. 
This  danger  is  not  present  when  local  anesthesia 
is  used. 

The  use  of  cocaine  spray  to  produce  nasal 
pharyngeal  or  laryngeal  anesthesia  is  to  be  con- 
demned because  too  much  unnecessary  surface  is 
anesthetized  and  too  much  cocaine  is  absorbed, 
it  being  not  possible  to  regulate  the  dose.  To 
anesthetize  pharyngeal,  laryngeal  and  nasal  mu- 
cous membranes  many  operators  use  strong  solu- 
tions ranging  from  10%  to  20%;  most  operators, 
however,  use  4%  to  5%  solution  first.  The  saliva 
and  mucus  are  wiped  off  from  the  surface,  as  they 
dilute  and  retard  the  production  of  the  anesthesia. 
Should,  during  any  operations  under  cocaine 
anesthesia,  sensibility  of  part  anesthetized  return, 
more  cocaine  solution  must  be  applied  to  the 
tissues,  it  being  remembered  that,  once  a  tissue  has 
been  brought  under  the  influence  of  cocaine,  it  is 
very  quick  to  respond  to  subsequent  applications 
during  the  entire  duration  of  the  operation.  Use 
cocaine  in  tonsilotomy,  especially  if  both  tonsils 
are  to  be  cut.  The  patient  not  experiencing  any 
pain  when  the  first  tonsil  is  cut,  willingly  submits 
to  the  excision  of  the  second.  By  the  application 
of  cocaine  to  the  surface  of  the  tonsils,  anesthesia 
of  the  deeper  parts  is  not  obtained.    This  however, 


138  *        GENERAL    AND    LOCAL    ANESTHESIA. 

is  not  a  great  drawback,  as  the  chief  seat  of  pain, 
in  section  of  the  tonsils,  is  the  mucosa. 

For  the  removal  of  naso-pharyngeal  adenoids  in 
adolescents  and  in  adnlts  for  the  removal  of  polypi 
and  of  multiple  papillomata  of  the  larynx,  cocaine 
anesthesia  is  serviceable.  When  cauterizing  or 
applying  caustics  to  diseased  portions  of  larynx 
see  that  cocainization  is  complete;  have  a  cotton 
wad  firmly  wound  around  the  end  of  a  probe  so 
that  it  wont  detach  itself,  and  after  moistening 
in  cocaine  solution,  under  guidance  of  a  mirror, 
rub  vigorously  against  the  laryngeal  mucosa. 

COCAINE     IjST     nasal     SURGEKY. 

In  nasal  surgery,  cocaine  is  a  favorite  anesthetic. 
When  used  the  head  can  be  kept  in  proper  position 
for  illumination  of  part.  Every  step  of  the  oper- 
ation can  be  seen.  Under  general  anesthesia  this 
can  not  be  done.  It  is  useful  to  the  rhinologist 
for  the  removal  of  deep  as  well  as  superficial  tissue 
abnormalities,  by  promoting  quiet,  by  lessening 
hemorrhage,  by  preventing  secretion  and  sneezing. 
By  its  contractile  effect  on  the  erectile  tissues,  the 
employment  of  cutting  instruments  in  the  nares 
is  facilitated  and  the  operator  is  enabled  to  examine 
the  field  of  operation  easily.  The  removal  of 
pedunculated  growths,  of  excrescences  of  the  nasal 
septum  and  other  similar  operations  come  within 
the  province  of  cocaine  anesthesia. 


COCAINE    IT    OTOLOGY. 


139 


In  order  to  anesthetize  the  nasal  mucous  mem- 
brane put  in  the  nostril  to  be  anesthetized  a 
pledget  of  cotton  saturated  with  cocaine  solution. 
The  pledget  must  be  large  enough  to  occlude  the 
nostrils;  every  two  or  three  minutes  until  the  part 
is  fully  anesthetized  instill  a  few  drops  of  solution 
on  cotton  in  situ.  The  pledget  of  cotton  must  be 
in  contact  with  the  area  to  be  anesthetized  for 
about  five  minutes.  In  using  cocaine  in  nasal  sur- 
gery, be  watchful.  Owing  to  the  fact  that  the 
mucous  membrane  covering  the  turbinated  bones 
of  the  nose  absorbs  this  agent  with  great  rapidity, 
accidents  are  liable  to  follow  its  use  in  this  region. 
Joseph  S.  Gibb  recommends  general  anesthesia  in 
the  following  intranasal  operations: 

(1)  Major  operations  involving  considerable  dis- 
section. 

(2)  Large  bony  deflections  requiring  breaking 
the  septum  at  its  base. 

(3)  Eemoval  of  large  bony  spurs. 

(4)  Congenital  or  acquired  stenosis. 

(5)  Plastic  operations. 

COCAINE    IN    OTOLOGY. 

Cocaine  is  of  service  to  the  otologist  in  the 
following  conditions: 

(1)  Application  of  painful  remedies,  such  as 
nitrate  of  silver,  alcohol,  etc.,  in  case  of  chronic 
purulent   otitis,   can  be   made   to  the  ear  after 


140  GENERAL    AND    LOCAL    ANESTHESIA. 

cocainizatiou,  with  little,  if  any,  pain  being  experi- 
enced by  the  patient.  (2)  Operations  on  the  walls 
of  ear  canal,  auricle  and  its  surroundings,  such  as 
removal  of  small  tumors,  incisions  into  the  skin, 
can  be  rendered  painless  by  injections  of  cocaine. 
(3)  Manipulations,  such  as  scraping,  torsion,  avul- 
sion, ecrasenient,  etc.,  in  tympanic  cavity  can  be 
performed  painlessly  under  local  anesthesia  when 
the  drumhead  is  perforated,  (-i)  The  following 
otological  operations  can  be  performed  under  local 
anesthesia:  Paracentesis  of  tympanum,  incision 
of  its  anterior  and  posterior  fiods;  tenotomy  of  the 
tensor  muscle,  section  of  the  handle  of  the  malleus, 
and  many  others. 

GENERAL     SUEGEEY. 

Eemoval  of  cutaneous  tumors,  as  sebaceous  cysts, 
rodent  ulcers;  excision  of  single  ganglia  about  wrist 
and  ankles,  opening  of  abscesses,  perineal,  ischio- 
rectal and  others;  tenotomies;  operations  on  hydro- 
cele, serous  cyst  of  neck,  tracheotomy,  tapping  of 
abdominal  and  thoracic  cavities;  all  these  opera- 
tions can  be  done  and  should  be  done  under  cocaine 
or  beta-eucaine  anesthesia. 

When  local  anesthesia  of  the  skin  or  deeper 
tissues  is  required,  the  cocaine  or  beta-eucaine 
solution  must  be  injected  hypodermically  into  the 
deeper  layers  of  the  skin  and  into  the  cellular  tissue 
of  the  parts  to  be  operated  upon.    To  avoid  mul- 


COCAINE   IN   GENITO-URINARY   SURGERY. 


141 


tiple  punctures,  the  needle  is  not  completely  with- 
drawn from  the  wound,  but  its  direction  is  changed 
and  the  solution  is  thrown  into  different  portions 
of  the  tissues. 

GENITO-UKINAEY     SUEGEKY. 

Use  only  2%  solution  in  the  urethra,    (a)    To 
induce  cocaine  anesthesia  of  penile  prepuce  for 
circumcision:   Eetract  prepuce,  place  constriction 
band  around  base  of  penis;  inject  by  means  of  a 
fine  hypodermic  needle  ten  or  twelve  drops  of  2% 
cocaine  solution  into  the  internal  layer  of    the 
prepuce  about  one-half  inch  from  its  attachment 
to  the  glans  penis;    make  blebs  until  cervix  is 
completely  encircled  by  them.    Now  draw  prepuce 
forward,  and  at  that  point  elected  for  incision 
make  a  similar  line  of  blebs  on  the  external  pre- 
putial layer,    (b)   For  enlarging  meatus  urinarius 
painlessly,  to  anesthetize  area,  place  a  tablet  of 
cocaine  just  within  the  meatus  and  let  it  dissolve 
there,    (c)  Previous  to  cauterizing  chancroids  and 
ulcers  of  other  nature,  have  the  patient  wash  them 
thoroughly  and  then  apply  your  cocaine  solution 
vigorously;    another  method  is  to  powder  a  few 
cocaine  tablets  and  dust  them  on  the  ulcers;  they 
will  dissolve  in  the  secretions  and  anesthetize  the 
surface,     (d)    In  the  removal  of  vulvar,  urethral 
and  anal  vegetations;    in  the  cauterization  and 
scarification   of  the   uterine   cervix;   when  it   is 


142  GENERAL    AND    LOCAL    ANESTHESIA. 

desired  to  cauterize  vulvar  vaginal  mucous  mem- 
brane in  gonorrheal  inflammations,  cocaine  is  the 
anesthetic  to  resort  to.  Though  curettage  of  the 
uterine  cavity  has  been  successfully  performed 
under  cocaine  anesthesia,  I  prefer  in  that  oper- 
ation the  aid  of  general  anesthesia,  (e)  In  internal 
urethrotomy  inject  a  1%  solution  in  the  urethra 
compress  the  meatus  so  that  the  solution  will 
sojourn  in  the  urethra. 

In  rectal  surgery,  when  six  injections  are  made 
equidistant  around  the  anus,  the  forcible  dilata- 
tion of  the  orifice  is  not  painful.  The  ligation  of 
small  hemorrhoidal  tumors  can  be  performed 
under  cocaine  anesthesia;  if  the  hemorrhoids  are 
to  be  cauterized,  the  infiltration  method  of  anes- 
thesia is  preferable  to  cocaine  anesthesia,  as  incan- 
descent heat  destroys  the  drug.  In  anal  work,  the 
rich  lymphatic  and  vascular  supply  of  the  part 
increases  the  liability  to  cocaine  intoxication. 

Cocaine  anesthesia  is  of  service  as  an  aid  to 
diagnosis:  (a)  To  differentiate  the  gians  penis 
pain  from  renal  pain,  (b)  To  examine  the  eye- 
ball and  conjunctival  sac.  Anesthesia  of  the  eye- 
ball abrogates  that  reflex  movement  of  the  lids. 
This  is  of  value,  in  trying  to  locate  a  foreign  body 
in  the  conjunctival  sac  or  imbedded  in  the  cornea, 
in  blepharospasm,  etc.  (3)  Applications  of  cocaine 
to  the  palate,  to  the  uvula  and  to  the  posterior 
pharyngeal  wall   greatly  facilitate,   especially  in 


COCAINE   AS   AN   AID   TO   DIAGNOSIS.  143 

hypersensitive  patients,  laryngoscopical  and  pos- 
terior rhinoscopical  examinations.  It  does  this  by 
abolishing  reflex  phenomena  and  by  diminishing, 
or  abolishing,  temporarily,  tactile  hyper-sensibility. 
(4)  In  anterior  and  posterior  rhinoscopy,  by  abol- 
ishing reflex  excitability,  by  diminishing  or  abol- 
ishing dolorous  sensibility,  by  contracting  the 
vessels  of  the  congested  nasal  miicons  membrane, 
it  facilitates  the  use  of  instruments  in  the  nasal 
cavities.  Cocaine,  owing  to  its  contractile  effect 
on  erectile  tissues,  enables  the  operator  to  examine 
the  nares  more  closely.  In  nasal  polypus,  by 
diminishing  the  swelling  around  it,  it  makes  the 
polypus  more  prominent.  (5)  For  rectal  examina- 
tions, especially  when  it  is  desired  to  palpate  the 
prostatic  gland,  also  in  examining  for  anal  fissure. 
(6)  In  sounding,  and  in  examining  the  bladder 
by  cystoscopy.  In  case  of  alarming  symptoms 
appearing,  rapidly  empty  the  bladder  and  then 
wash  it  out.  Very  little  absorption  takes  place 
from  the  vesical  mucous  membrane.  However,  it 
is  unsafe  to  use  cocaine  solution  in  the  bladder 
if  any  dissolution  in  the  continuity  of  the  lining 
membrane  of  the  bladder  is  present.  The  anes- 
thetization by  cocaine  of  the  urinary  vesical 
mucous  membrane  having  been  attended  in  some 
cases  by  the  production  of  alarming  symptoms, 
many  genito-urinary  surgeons  now  use  antipyrin 
to  anesthetize  the  vesical  mucous  membrane.    (?) 


144  GENERAL    AND    LOCAL    ANESTHESIA. 

For  the  vaginal  examination  of  highly  nervous  and 
hyperesthetic  wonien^  cocaine  may  be  applied  to 
the  vaginal  orifice. 

COCAINE     AS     A     THERAPEUTIC     AGENT. 

As  a  therapeutic  agent,  the  anesthetic  proper- 
ties of  cocaine  are  made  nse  of:    (a)    To  lessen 
the  pain  associated  with  superficial  inflammation 
of  the  eyeball,  especially  those  of  the  cornea,     (b) 
To  reduce  the  sensibility  of  a  painful  membranum 
tympani.     (c)    To    lessen    the    pain   incident    to 
fissured  nipples,   it  must   always  be  washed  off 
before  putting  child  to  the  breast.     Orthoform, 
being  non-toxic,  is  for  this  purpose  preferable  to 
cocaine.     Another  objection  to  cocaine  in  this  con- 
dition,   is    that    it    unfavorably    influences    the 
secretion  of  milk,     (d)  To  combat  dysphagia;  in 
cases  of  pharyngeal  stenosis  produced  by  tumors, 
in  pharyngeal  or  laryngeal  phthisis  and  syphilis, 
in  tonsillitis,  in  ulcers  of  the  pharynx,  epiglottis 
or  larynx,  the  pain  produced  by  swallowing  is 
at  times  so  severe  that  patients  either  refuse  or 
are  unable  to  take  nourishment.     By  cocainizing 
the  painful  parts,  the  pain  incident  to  the  par- 
taking of  food  in  these  conditions  is  mitigated  or 
stopped.     Patients    can  then  take   nourishment. 
This,  the  taking  of  nourishment,  in  all  diseases, 
is  an  important  adjuvant  to  medicinal  measures, 
(e)  To  facilitate  the  introduction  of  the  stomach- 


COCAINE   AS   A  THERAPEUTIC   AGENT.  145 

tube  when  lavage  or  gavage  of  the  stomach  are 
indicated.  Before  introducing  the  stomach-tube 
paint  vigorously  the  posterior  buccal  and  pharyn- 
geal mucous  membrane  with  a  10%  cocaine  solu- 
tion. This  abolishes  the  sensitiveness  of  the  parts 
and  spares  the  patient  the  pain  and  nausea  incident 
to  this  procedure,  when  anesthesia  of  the  fauces 
has  not  been  previously  secured.  If  in  the  absence 
of  cocainization,  swallowing  of  the  stomach-tube 
causes  patient  little  or  no  discomfort,  the  use  of 
cocaine  is  not  indicated  and  should  not  be  resorted 
to. 

(f)  In  hyperemesis  gravidarum,  Lutaud  rec- 
ommends ten  drops  of  1%  or  3%  cocaine  solution, 
repeated  at  one  or  two  hours'  intervals.  In  the 
gastric  crises  of  tabes,  the  introduction  into  the 
stomach  of  five  ounces  of  water  containing  from 
one-half  to  one  grain  of  cocaine  is  most  always 
followed  by  a  palliation  if  not  by  a  cessation  of 
the  pain.  In  stomatitis,  in  gastralgia,  in  boulimia, 
owing  to  its  benumbing  influence  on  the  mucous 
membranes,  it  is  a  valuable  palliative  agent,  (g) 
In  catheterization  of  the  Eustachian  tubes  through 
the  nose,  this  procedure  is  greatly  facilitated  by 
previously  applying  cocaine  to  the  nasal  passage 
and  to  the  pharyngeal  orifice  of  tubes,  by  means 
of  an  atomizer,  a  brush,  or  with  cotton  on  a 
probe.  Under  the  influence  of  the  cocaine,  the 
mucous  membrane  becomes  insensible,  and  then 


146  GENERAL    AND    LOCAL    ANESTHESIA. 

the  catheter  glides  over  the  parts  without  causing 
any  pain,  owing  to  the  greater  patulousness  of  the 
nasal  passages.  In  most  individuals,  catheteriza- 
tion of  the  Eustachian  tubes,  introduction  of  the 
stomach  tube,  catheterization  of  urethra  and  exam- 
ination of  rectum  can  easily  be  performed  without 
the  aid  of  cocaine  anesthesia.  When  the  employ- 
ment of  a  toxic  agent  is  not  required,  its  use  should 
not  be  resorted  to.  (h)  After  operation  for 
hemorrhoids,  under  general  anesthesia,  a  cocaine 
suppository  is  comforting  to  the  patient.  In  pain- 
ful hemorrhoids,  cocaine  suppositories  can  be  used 
with  advantage,  (i)  In  anal  fissure,  to  obtain 
painless  stools,  so  as  to  operate  without  general 
anesthesia  (anal  dilatation  can  be  performed  under 
cocaine  anesthesia);  in  spasm  of  sphincter  ani,  to 
relieve  anal  itching  of  hemorrhoids;  in  all  these 
conditions,  cocaine,  owing  to  its  paralyzing  action 
on  the  peripheral  sensory  nerve  filaments,  is  of 
service.  Use  a  tampon  soaked  in  5%  solution 
and  apply  to  fissure  or  insert  in  the  rectum  as 
indicated,  (j)  In  vulvar  and  preputial  pruritus, 
avail  yourself  of  the  action  of  cocaine  on  peripheral 
sensory  nerve  filaments.  Also  in  eczema  of  the 
anus  and  of  the  genital  organs. 

(k)  The  employment  of  such  agents  as  chromic 
acid,  the  galvanocauterj-,  etc.,  etc.,  is  by  the  use 
of  cocaine  made  comparatively  j)ainless.  "Cocaine 
solution  applied  for  a  few  minutes  to  the  surface 


COCAINE    AS    A    THERAPEUTIC    AGENT. 


147 


of  an  ulcer  which  is  to  be  cauterized,  will  render 
the   operation   almost   painless   to   the   patient.'' 
(Wharton.)    The  efficacy  of  the  destructive  agent 
is  not  affected  by  cocaine.    The  ulcerated  surface 
is  to  be  swabbed  vigorously  with  10%  solution. 
If  the  cauterization  or  curettage  is  to  be  deep,  some 
of  the  cocaine  must  be  injected  in  the  tissues. 
(1)    When,  a  few  drops  of  a  solution  of  cocaine, 
2%  to  5%,  are  injected  into  the  urethra,  a  catheter 
can  be  introduced  without  pain,  provided  there 
is  no  stricture.     Be  cautious  as  to  its  use  here. 
Most  of  the  cases  of  cocaine  poisoning  have  fol- 
lowed its  use  about  the  urinary  organs,     (m)   In 
vaginismus,  the  swabbing  of  the  vaginal  walls  with 
a   cocaine   solution,  then   following  this   with   a 
vaginal    injection    of    a    weak    cocaine    solution, 
though  it  will  not  cure  the  condition,  will,  how- 
ever, suppress  one  of  its  annoying  inconveniences. 
Coitus  is  made  possible  and  painless  to  the  woman. 
Conception  is  thus  facilitated.    In  this  condition, 
I  have  found  the  local  use  of  the  following  mixture 
valuable : 

Cocaine  hydrochlorate 30 

Distilled  water 30.00 

Alcohol 10.00 

(n)  In  localized  neuritis,  the  cataphoric  use  of 
cocaine  is  valuable.  Place  the  positive  pole  over 
the  affected  nerve;  it  is  the  sedative  pole.  You  get 


148  GENERAL    AND    LOCAL    ANESTHESIA. 

the  analgesic  action  of  the  electricity  and  the 
analgesic  action  of  the  cocaine. 

1.  Observe  the  same  aseptic  and  antiseptic  pre- 
cautions in  operations  done  under  local  anesthesia 
that  you  do,  or  should  do,  in  operations  performed 
under  general  anesthesia,  (a)  Rigid  surgical 
cleanliness  of  field  of  operation  and  irrigation  with 
antiseptic  solutions,  (b)  Thorough  sterilization 
of  all  instruments  and  of  all  objects  that  are  to 
come  in  contact  with  the  field  of  operation. 
(c)  Strict  observance  by  surgeon  and  his  assistants 
of  modern  surgical  antiseptic  teachings.  Needle 
and  syringe  used  should  be  aseptic.  Needle  can 
be  boiled  and  a  syringe  full  of  alcohol  passed 
through  it  previous  to  using. 

2.  Solutions  used  should  be  freshly  prepared. 
Solutions  of  cocaine  with  age  lose  their  anesthetic 
properties;  they  decompose  and  become  septic; 
moulds  form  in  them.  Only  distilled  or  filtered 
sterilized  water  or  sterilized  normal  salt  solution 
should  be  used  for  these  solutions.  The  steriliza- 
tion of  solution  by  heat  after  the  cocaine  is  dis- 
solved in  the  water,  decomposes  the  cocaine,  more- 
over, it  is  superfiuous,  as  unadulterated  cocaine  is 
sterile.  If  you  keep  on  hand  some  cocaine  solution, 
never  load  your  syringe  directly  from  the  bottle. 
Sterilize  a  small  glass,  pour  into  it  your  cocaine 
solution  (a  quantity  exceeding  slightly  in  amount 


METHOD    OF    USING    COCAINE. 


149 


that  which  you  will  need  for  the  case  at  hand)  and 
load  your  hypodermic  from  glass  contents. 

Non-sterile  solutions  give  rise  to  suppuration 
in  wound.  The  humors  of  the  eye,  the  body  juices 
are  good  culture  media  for  germs. 

3.  The  cocaine  employed  should  be  absolutely 
pure.  Laborde  has  pointed  out  that  its  mixture 
with  other  alkaloids  forms  highly  poisonous  com- 
pounds. 

4.  According  to  Eeclus,  who  has  a  record  of 
3,500  successful   cocainizations,  the  dose  should 
not  exceed  one-fifth  grain  for  small  operations, 
one  to  three  grains  in  large  operations.     When 
the  latter  amount  is  used,  great  watchfulness  must 
be  exercised.    The  dose  of  cocaine  should  be  appro- 
priate to  the  extent  of  surface  desired  to  render 
insensitive.    A  large  dose  should  never  be  used  at 
one  time,  but  fragmented,  given  at  intervals.    The 
slow  administration  of  cocaine  rendering  it  possible 
to  guard  against  the  production  of  sudden  symp- 
toms of  poisoning.    Injections  can  be  made  as  the 
operation     progresses.      Concentrated     solutions 
should  never  be  employed,  the  danger  from  their 
use  is  too  great  rapidity  of  absorption. 

A  weak  solution  permits  a  minimal  amount  of 
cocaine  to  reach  a  maximal  extent  of  surface.  The 
danger  of  cocaine  anesthesia  is  proportional  to 
the  actual  quantity  of  the  alkaloid  used  and  not 
to  the  amount  of  solution  used.    Eeclus,  when  he 


150         GENERAL  AND  LOCAL  ANESTHESIA. 

uses  cocaine  subcutaneously,  confines  himself  to 
a  1%  solution.  With  cocaine^  when  practical,  it  is 
well  to  make  injections  over  the  course  of  the 
sensory  nerves  in  the  part. 

5.  The  use  of  a  constricting  band  or  tourniquet, 
when  practicable,  as  in  operations  on  extremities, 
as  in  circumcision,  should  never  be  omitted.  In 
performing  castration  under  cocaine  anesthesia, 
surround  base  of  scrotum  with  an  elastic  ligature. 
By  the  use  of  the  constricting  band  or  tourniquet 
the  action  of  the  drug  is  limited  to  desired  area. 
Before  applying  tourniquet,  elevate  part  to  expel 
blood  from  same.  The  constrictor  is  applied  at 
some  point  between  the  site  of  proposed  operation 
and  the  trunk.  It  is  drawn  tighly  enough  to  cut 
off  the  blood  supply  to  the  part.  "When  we  shut 
off  the  blood  from  a  portion  of  the  body  previously 
injected  with  a  comparatively  weak  solution  of 
hydrochlorate  of  cocaine,  we  maintain  the  latter 
for  a  protracted  period  of  time  in  contact  with 
the  filaments  of  the  sensory  nerves;  and  are 
consequently  enabled  to  prolong  in  the  sensory 
filaments  those  chemical  changes  which  are  neces- 
sary for  the  suspension  of  their  functional  activit}^ 
for  the  maintenance  of  the  condition  of  anesthe- 
sia."    (Leonard  Corning.) 

This  constriction  prevents  the  rapid  absorption 
of  the  drug  into  the  general  circulation  and  the 
dangers   of   intoxication   incident   to    this   rapid 


METHOD   OF   USING    COCAINE.  151 

absorption.  Owing  to  lessened  tendency  to  absorp- 
tion, more  latitude  for  the  use  of  the  drug  is 
obtained.  When  this  elastic  ligature  is  removed, 
the  bleeding  from  the  stump  washes  out  the  excess 
of  the  drug.  "The  incision,  the  manipulation  and 
the  free  bleeding  which  follows  the  removal  of  the 
constrictor  should  remove  a  considerable  portion 
of  cocaine.''    (Thompson.) 

6.  In  some  cases,  the  constricting  band  is  use- 
ful, because  it  secures  a  wound  unobscured  by 
blood.  Anemia  facilitates  the  production  of  anes- 
thesia. In  operating  on  a  limb,  after  the  comple- 
tion of  the  operation,  the  tourniquet  is  loosened 
for  three  or  four  seconds  and  then  reapplied  for 
several  minutes;  this  procedure  is  repeated  two 
or  three  times.  In  this  way  only  a  small  quantity 
of  cocaine  is  admitted  into  the  circulation  at  one 
time  and  this  small  quantity  distributed  over  a 
large  area  produces  no  ill  results. 

7.  Extreme  caution  in  the  use  of  cocaine  is 
to  be  employed,  when  the  circulation  cannot  be 
controlled.  First  inject  one  centigram  of  the 
drug;  if  no  untoward  symptoms  occur,  there  is 
no  idiosyncrasy.    You  can  then  inject  more., 

8.  Injections  should  always  be  practiced  with 
patient  in  recumbent  posture,  and  he  should  only 
be  raised  Avhen  the  operation  is  to  be  performed 
upon  the  mouth  or  throat,  and  then  only  when 
the    anesthesia   is    complete.     (Magitot,   Keclus.) 


152  GENERAL    AND    LOCAL    ANESTHESIA. 

The  recumbent  posture  is  imperative  in  cocaine 
anesthesia.  (Dujardin-Beaumetz.)  Eeclus  insists 
upon  the  patient  being  kept  in  the  recumbent 
posture,  and  adds  that  syncope  in  cocainization  is 
the  fault  of  the  administrator  and  not  of  the 
cocaine.  He  makes  patients  l^eep  recumbent  pos- 
ture for  from  two  to  three  liours  after  the  com- 
pletion of  the  operation,  and  does  not  permit  them 
to  arise  until  they  have  eaten  something. 

9.  When  the  operation  involves  the  skin,  the 
injection  should  be  made  into  the  derma  itself 
and  not  into  the  subcutaneous  cellular  tissue. 
Anesthesia  of  the  skin  by  cocaine  is  obtained  only 
through  endermatic  injections.  Cocaine  cannot 
be  absorbed  through  the  unbroken  skin.  Hypoder- 
matic injections  secure  subcutaneous  anesthesia, 
but  not  cutaneous. 

You  will  know  that  you  are  injecting  the  solu- 
tion in  the  cutaneous  tissues  by  experiencing  the 
resistance  which  the  dermal  tissues  offer  to  the 
advance  of  the  hypodermic  needle  and  by  noting 
the  formation  of  bleb-like  swellings  along  the  line 
of  injection.  Introduce  the  needle  about  parallel 
to  the  skin. 

10.  Do  not  inject  the  solution  into  a  vein.  Many 
of  the  accidents  that  have  occurred  under  cocain- 
ization, and  that  have  been  attributed  to  idiosyn- 
crasy, were,  in  reality,  due  to  the  injection  of  the 
drug  directly  into  the  veins.    With  proper  precau- 


method][of  using  cocaine.  153 

tions,  even  in  regions  rich  in  veins,  this  should  not 
occur.  This  is  avoided  by  gradually  expelling 
solution  from  the  syringe  at  the  same  time  that 
the  needle  is  gradually  withdrawn  from  the  tissues. 
Leonard  Corning  advises  the  following  to  avoid 
injecting  cocaine  solutions  in  veins:  Pass  a  piece 
of  ordinary  elastic  webbing  around  the  central 
portion  of  the  limb;  draw  it  sufficiently  tight  to 
cause  swelling  of  the  superficial  veins.  It  is  now 
an  easy  matter  to  trace  out  the  course  of  the  dis- 
tended vessels  with  an  ordinary  colored  pencil,  so 
that  when  the  ligature  is  removed  these  topo- 
graphical reminders  remain  upon  the  surface. 

11.  Expel  the  solution  of  cocaine  from  the 
syringe  drop  by  drop,  while  the  needle  is  passing 
through  the  tissues.  The  object  of  this  is  to  con- 
trol the  largest  possible  field  with  a  single  injec- 
tion; that  is  obtaining  the  maximal  effect  with  the 
minimal  dose.  Make  cocaine  injections  in  an 
orderly  manner.  Inject  the  sub-epidermal  tissues 
first  and  subsequently  the  deeper  tissues.  If  the 
operation  to  be  done  requires  deep  dissection,  in- 
jections must  be  both  superficial  and  deep.  Swab, 
if  needed,  field  of  operations  with  cocaine  solution, 
every  few  minutes. 

12.  Let  at  least  five  minutes  elapse  after  the 
first  application  or  injection  before  applying  the 
knife. 

13.  In  inducing  local  anesthesia  for  the  enu- 


154  GENERAL    AND    LOCAL   ANESTHESIA. 

cleation  of  a  small  tumor  located  near  the  surface 
of  body,  inject  solution  beneath  and  around  tumor 
so  as  to  bathe  neoplasm  in  the  anesthetic  fluid. 
Its  dissection  will  then  not  be  attended  with  any 
suffering. 

When  giving  cocaine,  always  have  some  aromatic 
spirits  of  ammonia,  some  nitrite  of  amyl  and  some 
ether  at  hand.  These  are  useful  agents  with 
which  to  combat  cocaine  intoxication.  Upon  the 
first  appearance  of  symptoms  of  poisoning,  have 
(a)  patient  immediately  assume  the  recumbent 
posture.  Recovery  takes  place  more  rapidly  in  this 
posture,    (b)   Give  hypodermic  injections  of  ether. 

ACCIDENTS    AND    THEIR    REMEDIES. 

Accidents  are  often  due  to  the  faulty  technique 
of  the  physician,  such  as  the  use  of  an  overdose, 
failure  to  have  patient  maintain  the  recumbent 
posture,  non-employment  of  means  that  prevent 
too  rapid  absorption,  as  the  constricting  band  or 
tourniquet,  the  use  of  an  adulterated  product,  etc. 
Among  the  symptoms  of  poisoning  may  be  men- 
tioned loquacity,  cold  perspiration,  shallow  respi- 
rations, rapid,  feeble  pulse,  unconsciousness  and 
convulsions.  Cocaine  can  cause  death  by  causing 
paralysis  of  the  respiratory  center  or  tetanic  fixa- 
tion of  respiratory  muscles. 

In  paralysis  of  respiratory  center: 

a.  Elevate  trunk  and  lower  head. 

b.  Practise  artificial  respiration. 


INFILTRATION    ANESTHESIA.  155 

c.  Give  stryclminae  sulph,  gr.  1-20  hypodermi- 
cally.  It  is  the  best  respiratory  stimulant  that  we 
have. 

d.  Give  amyl  nitrite,  or  hypodermics  of  nitro- 
glycerine. 

In  tetanic  fixation  of  respiratory  muscles  give: 

a.  Inhalations  of  amyl  nitrite. 

b.  Chloral  and  bromide  in  the  form  of  enemata. 

e.  Morphine  sulph. 

Morphine,  though  not  an  absolute  antidote,  is 
most  valuable  in  counteracting  the  toxicity  of 
cocaine.  "There  exists  a  marked  antagonism 
between  cocaine  and  morphine,  also  between 
cocaine  and  chloroform  or  ether."  (Willard  and 
Adler.) 

In  all  forms  of  cocaine  poisoning,  empty  the 
bladder  and  activate  urinary  secretion.  Meet  sleep- 
lessness by  hypnotics  oi  narcotics.  In  delirium 
due  to  cocaine  intoxication,  if  the  heart  be  not 
very  weak,  chloral  can  be  used  or  hyoscine  hypo- 
dermatically.  If  patient  be  very  delirious,  he  will 
have  to  be  restrained. 

Infiltration  Anesthesia. 

The  technique  of  this  method  was  first  elabor- 
ated and  introduced  to  the  medical  world  by  Dr. 
C.  L.  Schleich  of  Berlin.  It  is  based  upon  the 
fact  that  endermatic  injections  or  infiltration  of 
the  various  tissues  of  the  body  with  water,   or 


156  GENERAL    AND    LOCAL   ANESTHESIA. 

watery  solutions  of  indifferent  substances  will  pro- 
duce local  anesthesia  of  the  tissues  infiltrated. 
Previous  to  the  introduction  of  Schleich's  infil- 
tration method  of  local  anesthesia,  deep  injections 
of  cold  water  along  the  course  of  the  sciatic  nerve 
were  made  with  alleged  benefit.  If  the  production 
of  the  anesthesia  is  preceded  by  the  production  of 
pain,  we  have  the  condition  which  is  called  anes- 
thesia dolorosa.  (Liebrich.)  ".03  parts  to  100 
parts  of  distilled  water  is  the  weakest  cocaine 
solution  which  can  produce  local  anesthesia  with- 
out prodromal  hyperesthesia."  (Schleich.) 
Infiltration  causes  anesthesia  by 

a.  Causing  an  anemia  of  the  part.  This  anemia 
is  due  to  the  compressing  action  exerted  by  the 
injected  fluid  on  the  bloodvessels. 

b.  Low  temperature  of  the  injected  solution.  Its 
temperature  must  always  be  lower  than  that  of  the 
body.  If  both  are  of  the  same  temperature,  the 
anesthetic  effect  is  greatly  diminished;  whereas 
if  the  solution  is  ice-cold,  anesthetic  action  is 
augmented. 

c.  The  mechanical  pressure  exerted  on  tissues, 
notably  on  nerve  filaments. 

d.  Direct  specific  but  not  destructive  effect  of 
injected  solution  on  the  nerves. 

e.  Destructive  chemical  action  on  the  nerves. 

f.  The  maintenance  of  complete  edema  of  the 
tissues  to  be  operated  on. 


INFILTRATION    ANESTHESIA. 


157 


The  anesthesia  produced  by  this  method  is  in- 
stantaneous. As  soon  as  the  tissues  have  been 
edematized,  they  are  anesthetic.  This  differs  from 
other  methods  of  local  anesthesia,  and  is  a  distinct 
advantage.  ^'Every  tissue  is  anesthetic  that 
can  be  artificially  edematized  by  our  solutions." 
(Schleich.)  This  holds  good  for  skin  and  mucous 
membrane,  periosteum,  synovial  membrane,  fascia, 
muscle,  lymph,  glands,  nerves,  viscera,  and  even 
bone. 

The  infiltration  method  of  anesthesia  is  unsuited 

for  use. 

a.  In  most  abdominal  and  pelvic  operations. 

b.  In  ophthalmic  surgery,  as  relating  to  the  eye- 
ball. Cocaine  is  the  ophthalmologist's  most  ser- 
viceable anesthetic. 

c.  In  nasal,  naso-pharyngeal  and  intra-laryngeal 
manipulations  and  surgery.  Dr.  Coulter,  however, 
uses  infiltration  anesthesia  when  performing  ton- 
sillectomy. (Eemoval  of  all  the  tonsillar  tissue 
through  mouth  by  means  of  the  galvano-cautery. 

d.  In  plastic  surgery,  the  artificial  edema  which 
is  the  basis  of  the  modus  operandi  of  ''the  infiltra- 
tion method"  interferes  with  the  nicety  of  surgical 
operations.  Infiltration  produces  an  extensive  arti- 
ficial edema  which  masks  anatomical  details  con- 
siderably, thus  rendering  the  operation  more  diffi- 
cult. Infiltration  by  distorting  the  flaps  increases 
the  difficulties  of  the  operation. 


158  GENERAL    AND    LOCAL    ANESTHESIA. 

e.  In  skin  grafting  operations.  Infiltration  im- 
pairs the  vitality  of  the  flaps.    (Lieberthal.) 

f .  Whenever  the  limits  of  the  disease  are  not 
readily  definable  as  in  malignant  tumors.  The 
presence  of  much  fluid  in  the  tissues  changes  their 
appearance  and  renders  difflcnlt  the  demarcation 
of  sound  from  diseased  tissues. 

g.  In  diffuse  cellulitis,  requiring  free  incisions, 
h.  In  cases  of  malignant  new  growths,  of  diffuse 

tuberculosis^  etc.  The  increased  hyper  tension  of 
part  makes  possible  the  forcing  of  the  materies 
morbi  into  the  lymph  channels.  "In  the  removal 
of  large  neoplasms  or  large  purulent  collections 
the  infiltration  method  is  not  suitable.'^  (Brauu, 
Leipzig.)  There  is  danger  that  the  repeated  needle 
punctures  may  disseminate  an  already  existing 
infectious  material  into  previously  healthy  parts. 

i.  In  all  cases  where  local  anesthesia  is  contra- 
indicated  as  in  very  nervous  patients  who  dread 
watching  the  surgeon's  manipulations. 

j.    In  children. 

With  this  method,  anesthesia  occurs  at  the  m_o- 
ment  of  completion  of  artificial  edema  and  not 
before.  It  lasts  from  10  to  15  ininutes  and  can 
be  prolonged  by  further  addition  of  the  fluid.  No 
part  is  to  be  operated  on  before  the  artificial 
edema  is  complete. 

The  quantity  of  toxic  agents  present  in  the 


BRAUN  S   FORMULA. 


159 


solutions  employed  is  so  small  that  the  use  of 
comparatively  large  quantities  of  the  solutions  is 
attended  with  ]io  risks  of  drug-poisoning.  Dif- 
ferent solutions  have  been  used.  Arthur  E.  Barker 
(London)  uses  the  following,  worked  out  by  Braun. 
He  says  that  it  can  be  used  practically  in  any 
amount  without  danger  of  producing  poisonous 
effects. 

BliAUN'S     (LEIPZIG)     FORMULA. 

Beta-Eucaine  1  part  by  weight. 

Chloride  of  sodium 8    ''       " 

AVater 1000    "       " 

The  advantages  of  beta-eiicaine  over  cocaine 
are  that  it  is  far  less  toxic  and  that  it  admits  of 
thorough  sterilization  by  boiling. 

In  Braun's  formula,  beta-eucaine  is  the  only 
anesthetic  used  in  the  solution,  the  salt  simply 
preventing  irritation.  Prof.  Schleich  has  used  beta- 
eucaine  in  his  operative  work.  He  has  observed  its 
non-toxic  properties.  He  says  that  it  can  be  'sub- 
stituted for  cocaine  in  his  method  of  infiltration 
anesthesia.  Owing  to  the  absence  of  vaso-constric- 
tive  effects,  beta-eucaine  does  not  allow  of  so  blood- 
less an  operation  as  is  the  case  with  similar  doses 
of  cocaine  dissolved  in  normal  salt  solution. 

There  can  be  no  doubt  that  cocaine  and  beta- 
eucaine  are  simple  substances  to  be  considered  in 
the  selection  of  a  drug  for  infiltration  anesthesia; 


160  GENERAL    AND    LOCAL    ANESTHESIA. 

they  paralyze  without  irritation,  and  without  injury 
to  the  tissues;  and  they  effect  an  anesthesia  lasting 
enough  for  practical  purposes  even  in  extreme 
dilution. 

Most  operators,  however,  use  Schleich's  formulas. 
They  are  the  following: 

SCHLEICH'S  rOEMULAS. 

'No.  1.  strong — for  operations  on  highly  hyper- 
esthetic  areas.  Inflammation,  suppuration,  neu- 
ralgia. The  more  sensitive  the  parts  are  that  you 
operate  on,  the  greater  must  he  the  concentration 
of  the  cocaine. 

Cocaine  hydrochlor 2 

Morphine  hydrochlor 025 

Sodium  chloride  (ster.) 225 

Distilled  water  (ster.) 100. 

M.  et  adde  5%  acid  carbol.  gtt.  .     2. 

One  ounce  of  this  solution  contains  about  one 
grain  of  cocaine. 

No.  2.  N^ormal — for  operations  on  moderately 
hyperesthetic  areas. 

Cocaine  hydrochl 0.100 

Morphine  hydrochl 025 

Sodium  chL  (ster.) 2 

Distilled  water  (ster.) 100. 

M.  et  adde  5%  acid  carbol.  gtt.  .  .     2. 

One  ounce  of  this  solution  contains  about  one- 
half  grain  of  cocaine. 

No,  3.    Weak — the  weakest  possible  solution  for 


■  schleich's  methods.  161  i 

I 

! 

extensive  operations  to  be  used  alternately  with 

stronger  solutions:  | 

Cocaine  liydrochlor 01  \ 

Morphine  liydrochlor 005  i 

Sodium  chloride  (ster.) 2 

Distilled  water  (ster.) 100.  ^ 

M.  et  adde  5%  acid  carbol.  gtt.  .  .     2.  \ 

These  solutions  must  be  kept  absolutely  sterile.  \ 

These  ingredients  can  easily  be  prescribed  in  ', 

the  form  of  a  powder  to  be  dissolved  in  sterilized 
water  just  previous  to  using.    Every  practitioner  ] 

should  always  have  in  his  satchel  a  few  of  these  ; 

powders,  kept  in  a  sterilized  flask. 

Only  sterilized  water  must  be  used  in  the  prepa- 
ration of  the  solutions.     The  sodium  chloride  is  ; 
roasted  in  a  small  pan.    It  may  be  sterilized  by  \ 
boiling  in  a  small  amount  of  w^ter  in  a  well-  ■ 
cleansed  test-tube  and  then  allowing  it  to  cool.    It  i 
is  added  to  the  solutions  to  attenuate  the  irritating                      ; 
action  of  the  water.    The  one-fifth  per  cent  solu-                       ; 
tion  of  sodium  chloride  is  a  practical  anesthetic 
when  the  skin  is  healthy.    It  will  not  suppress  pain 
in     hyperesthetic     inflamed     areas.     (Schleich.) 
Inflamed  tissues  are  highly  sensitive.    To  do  thiS;, 
cocaine  is  added  to  the  solution.                                                   ' 

Morphine  does  not  need  to  be  sterilized.  Like 
cocaine  in  the  pure  state,  it  is  bacteriologieally 
sterile.  Heat  decomposes  these  alkaloids.  They 
should  be  weighed  on  a  well-cleansed  scale.    Mor-  j 


163 


GENERAL  AND  LOCAL  ANESTHESIA. 


Fig.  1. 


Fig.  2. 


Fig.  1.— Bransford  Lewis  Infiltration  Syringe. 
Fig.  2.— Formation  of  the  cutaneous  wheals.    A  spot  made  anes- 
thetic by  ether  spray  for  the  first  injection. 


schleich's  methods.  163 

phine  was  incorporated  in  Schleich's  solutions  for 
the  purpose  of  allaying  the  paresthesia  incident 
to  the  wearing  off  of  the  anesthesia.  As  stated, 
Schleich's  solutions  are  prepared  with  boiled  and 
filtered  water,  and  if  the  hands  and  instruments 
used  in  its  preparation  are  sterile  it  may  be  re- 
garded as  aseptic.  It  is,  however,  not  antiseptic, 
and  if  accidentally  contaminated  is  unfit  for  use. 

An  ordinary  hypodermic  needle  may  be  made  to 
serve  for  injecting  the  solution  in  many  cases.  It 
is  better,  however,  to  have  a  larger  syringe  with 
several  needles,  some  straight,  some  curved.  "The 
Bransford  Lewis  Infiltration  Syringe"  is  very  ser- 
viceable. The  barrel  of  the  syringe  is  large,  the 
needles  have  a  rounded  end^  or  probe  point,  which 
prevents  their  piercing  such  structures  as  veins, 
arteries  or  nerves. 

Such  operations  as  enucleation  of  buboes,  cir- 
cumcisions, castration^  colotomy,  cholecystotomy, 
drainage  of  empyema  of  thorax,  have  been  success- 
fully performed  under  infiltration  anesthesia. 
August  McLean  says  "The  infiltration  does  not 
appear  to  have  any  deleterious  effect  upon  the 
healing  of  the  tissues."  In  many  of  his  cases, 
there  was  primary  union. 

In  3,500  cases,  Schleich  did  not  once  convey 
infection  by  means  of  the  injected  fluid. 

In  beginning  to  use  the  infiltration  method, 
select  easy  cases,  such  as  ablation  of  small  tumors. 


164  GENERAL    AND    LOCAL    ANESTHESIA. 

suture  of  wounds.  As  your  experience  with,  the 
method  increases,  you  can  use  it  in  more  difficult 
cases.  Experience  will  perfect  your  technique. 
Each  case  teaches  something  which  will  perhaps 
be  useful  in  the  next. 

TECHNIQUE     OF     METHOD. 

1.  Scrub,  shave,  and  otherwise  prepare  field  of 
operation. 

2.  Observe,  and  have  your  assistants  observe, 
modern  antiseptic  teachings. 

3.  Needle,  syringe  and  anesthetic  solution  must 
be  sterile.  Syringe  must  be  in  good  working  order. 
It  is  very  annoying  to  have  a  leaking  syringe. 

4.  Place  the  bottle  containing  the  solution  on 
ice.  It  must  be  kept  on  ice  during  the  entire 
duration  of  the  operation.  The  anesthetic  prop- 
erties of  the  solutions  are  intensified  by  cold. 
Warm  solutions  are  unfit  for  anesthetic  use.  The 
syringe  should  also  be  cooled. 

5.  To  make  the  first  puncture,  by  needle,  pain- 
less, a  spray  of  chloride  of  ethyl  can  be  directed 
against  the  skin;  a  pledget  of  cotton  dipped  in 
cocaine  solution  placed  upon  the  mucous  mem- 
brane. 

6.  Insert  needle  in  skin,  holding  the  syringe 
at  an  angle  of  45°  to  the  skin.  Inject  sufficient 
of  solution  to  produce  a  wheal  about  the  size  of  a 
dime.  Remove  needle,  reintroduce  at  the  periphery 


TECHNIQUE   OF    METHOD. 


165 


but  still  within  the  wheal,  inject  enough  of  solu- 
tion to  form  a  new  wheal  and  repeat  this  process 
as  often  as  indicated.  In  this  way  the  line  of 
incision  is  anesthetized.  When  solution  is  thrown 
into  skin,  the  end  organs  of  the  sensory  nerves 
situated  there  immediately  absorb  the  solution  and 
are  temporarily  paralyzed.  (Barker,  London.) 
Anesthetize  skin  broadly,  so  that  the  suture  line 
will  be  infiltrated. 

Now  an  incision  can  be  made  through  the  skin, 
and  infiltration  of  the  deeper  tissues  proceeded 
with,  or  the  subcutaneous  tissues  can  be  squeezed 
full  of  fluid  through  the  anesthetized  skin.  The 
important  fact  being  that  all  tissues  that  come 
within  the  field  of  operation  must  be  edematized 
to  be  anesthetic.  Spots  which  have  not  been  infil- 
trated retain  their  sensibility.  If  the  tissues  to  be 
operated  on  are  not  very  deep,  it  is  better  to 
infiltrate  througli  the  skin.  Infiltration  in  the 
open  wound  is  more  difficult,  as  the  fluid  escapes. 
Do  not  infiltrate  through  the  skin  deeper  than  the 
superficial  muscles  except  in  cases  where  the  tissues 
to  be  anesthetized  are  superficially  located,  as  over 
the  skull^  over  the  clavicle,  over  the  sternum. 
When  tissues  are  dense,  considerable  pressure  is 
necessary  to  infiltrate  them. 

7.  The  field  of  operation  must  be  tensely  filled 
with  the  solution  before  beginning  to  operate.  If, 
during  operation  a  large  nerve  trunk  is  met,  it  may 


166 


GENERAL    AND    LOCAL    ANESTHESIA. 


Canula  tvith  pkce  of  wheat  formadon.     „ 

Iniroducing  anesthetic.  «u«iiv...      ^ 


Fig.  3.  Fig.  4. 

Fig.  3.— Diagram  of  a  section  of  the  skin,  showing  formation  of  the 
first  wheal. 

Fig.  4.— Infiltration  of  ingrowing  toe-nail. 


Pig.  5. 


Fig.  6. 


Fig.  5.— 1,  Fururcle;   2.  Anesthetized  skin;    8,  Infiltration  of  subja- 
cent tissue;  4  and  5,  First  and  second  position  of  syringe. 
Fig.  6. — Infiltration  of  abscess. 


T«f4fra  (Ad  sI';«aU'. 


Pig.  7. 


Fig.  8. 


Fig.  7.— Tumors. 

Fig.  8. — Infiltration  around  finger  going'  down  to  periosteum. 


TECHNIQUE   OF   METHOD.  167 

be  anesthetized,  for  a  short  time  only,  by  touch- 
ing it  with  a  5%  carbolic  acid  solution.  If  nerve 
is  to  be  cut,  it  must  be  infiltrated  separately.  If 
patient  during  operation  complains  of  the  slightest 
pain,  the  part  must  immediately  be  reinfiltrated. 
Pain  is  a  sign  of  insufficient  anesthesia,  insuf- 
ficient edematization.  As  soon  as  infiltration  is 
complete,  pain  is  absent.  "Tissues  not  thoroughly 
infiltrated  must  not  be  cut  or  manipulated." 
(Lund.)  The  surgeon  must  lay  down  the  knife  and 
take  up  the  syringe  on  the  slightest  expression  of 
pain  on  the  part  of  the  patient.  Should  it  become 
necessary  to  extend  the  field  of  operation  beyond 
the  infiltrated  area,  injections  must  be  made  in 
the  direction  required,  starting  from  within  the 
anesthetic  area. 

8.  Never  begin  tlie  infiltration  in  inflamed 
area.  Surround  it  and  advance  upon  it  from  all 
sides,  via  sound  skin.  Inflamed  tissues,  owing  to 
their  hypersensitiveness,  are  not  to  be  infiltrated 
until  the  adjacent  normal  tissues  are  infiltrated. 
Primary  injection  into  an  abscess,  phegmon  or 
pathological  focus  is  to  be  avoided  as  it  increases 
the  tension  and  does  not  lessen  the  pain. 

9.  Do  not  inject  contents  of  syringe  in  a  blood 
vessel.  If  operation  has  lasted  more  than  fifteen 
or  twenty  minutes,  it  will  be  necessary  to  anesthe- 
tize points  of  entrance  and  of  exit  of  suture  before 
closing  the  wound. 


168  GENERAL    AND    LOCAL    ANESTHESIA. 

Spray  is  applied  to  one  side  of  furuncle  and  the 
first  wheal  is  set  up  within  healthy  skin.  Push 
a  long  needle  in  an  oblique  direction  through  skin, 
expelling  the  solution  all  the  time  as  joii  advance 
and  deposit  an  anesthetic  focus  beneath  the  fur- 
uncle.   (Fig.  5.) 

Repeat  this  process  on  opposite  side  of  boil. 
Use  solution  freely.  Once  the  furuncle  is  com- 
pletely cut  off  from  the  surrounding  tissues  by  an 
anesthetic  zone,  anesthetize  the  skin  covering  it, 
beginning  within  the  infiltrated  area  and  advanc- 
ing towards  it.  Xow  incise  and  evacuate  and 
curette  the  furuncle. 

For  removal  of  sebaceous  cyst,  or  small  tumor, 
cut  skin  along  line  of  wheals,  severing  only  the 
skin.  Adapt  now  a  curved  needle  to  syringe. 
Raising  by  aid  of  forceps  the  cut  edge  of  the  skin, 
insert  needle  gently  and  gradually,  push  it  around 
underneath  the  cyst,  steadily  expelling  solution 
from  syringe  all  this  while.  The  tissue  beneath 
the  cyst  is  thus  anesthetized.  Xow  draw  out 
needle,  and  repeat  the  same  injecting  ^Drocedure  on 
the  other  side,  always  expelling  fluid  from  syringe 
as  needle  advances.  The  cyst  is  thus  wholly 
enveloped  by  edematious  and  anesthetized  tissue. 

Abscess.  Xever  inject  solution  in  abscess.  It 
increases  pressure  on  all  sides.  It  intensifies  the 
pain.  Begin  at  one  side  in  healthy  skin  and  pro- 
ceeding towards  abscess  anesthetize  by  the  forma- 


HOLOCAINE,    NIRVANINE   AND    ORTHOFORM.  169 

tion  of  intracutaneous  wheals,  the  skin  overlying 
the  abscess.  (Fig.  6.)  The  skin  being  infiltrated, 
infiltrate  subjacent  and  surrounding  tissues.    . 

The  accompanying  illustrations  portray  the 
technique  better  than  words. 

For  amputations  or  in  operations  upon  bone, 
the  periosteum  must  be  infiltrated  in  its  whole 
circumference.  AVhen  this  has  been  done,  bone 
may  be  divided  by  saw  or  forceps  without  unbear- 
able pain  being  caused.  The  medulla  of  bone  can 
be  infiltrated  through  an  opening  made  in  corlex 
of  the  bone. 

HOLOCAINE,  NIEVANINE,  ORTHOFORM. 

The  popularity  of  these  agents  is  increasing. 
Laboratory  experiments  show  that  when  properly 
employed  they  are  of  value  as  local  anesthetic 
agents.  Their  toxicity,  holocaine  excepted,  is  less 
than  that  of  cocaine.  They  have  a  sphere  of  use- 
fulness the  exact  extent  of  which  is  yet  to  be 
det^-mined.  It  can  only  be  determined  by  actual 
clinical  use.  The  objection  to  them  can  be  raised, 
as  it  can  with  all  other  local  anesthetic  agents,  that 
the  anesthesia  which  they  produce  is  not  as  com- 
plete as  that  secured  by  general  anesthetics.  To 
employ  them  to  good  advantage  one  must  know 
their  possibilities  and  also  their  limitations.  As 
with  many  other  valuable  drugs,  when  given  in 


170  GENERAL    AND     LOCAL    ANESTHESIA.  j 

doses  in  excess  of  the  therapeutic  dose,  they  are 

liable  to  cause  annoying  accidents.  j 

HOLOCAINE.  ' 

"Holocaine  is  the  ideal  local  anesthetic  for  re- 
moving foreign  bodies  from  the  conjunctival  sac/'  j 
(Knapp.)     "Holocaine  is  freely  soluble  in  boiling  j 
water,  but  sparingly  in  cold  water.     It  is  neutral  | 
in  reaction.     Having  germicidal  properties,  solu-  \ 
tions  of  holocaine  do  not  need  sterilization.  Boiling 
does  not  change  it  chemically  or  reduce  its  efficacy, 
but  as  a  1%   solution  is  decidedly  bactericidal^  i 
sterilization  by  heat  is  unnecessary."     (Louis  C.  j 
Dean.)    In  making  solutions  of  holocaine,  dissolve  ^ 
the  latter  in  a  porcelain  vessel,  as  it  causes  glass  ' 
containing  alkali  to  lose  a  portion  of  the  latter.  ] 
This  clouds  the  solution.     Holocaine  is  a  stable  j 
agent.    A  1  %  solution  will  remain  clear  for  about  ; 
two  months.  ''■ 

Applied  to  mucous  membrane,  it  produces  no  j 
constitutional  symptoms.  Administered  suj)cu-  i 
taneously,  it  is  a  poison.  No  poisonous  effect  from  j 
the  local  use  of  the  drug  has  ever  been  reported.  j 
The  toxic  dose  of  holocaine  when  administered  '. 
subcutaneously  or  internally,  is  oue  centigramme. 
Holcaine  is  used  extensively  in  ophthalmic  prac- 
tice. It  has  been  found  to  be  an  efficient  local  | 
anesthetic  in  eye  surgery.  It  seems  to  act  by  pro-  •  i 
ducing  a  paralysis  of  the  sensory  nerve  endings.  j 


HOLOCAINE. 


171 


Unlike  many  other  local  anesthetic  agents,  it 
causes  neither  ischemia  nor  freezing  of  the  part. 
Outside  of  rendering  the  eye  anesthetic,  holocaine 
has  no  other  effect  upon  it.  It  produces  anesthesia 
of  the  eye  without  producing  any  other  associated 
symptom.  It  acts  in  the  same  manner  in  contact 
with  the  hyperemic  or  granular  conjunctiva  as  in 
the  presence  of  a  normal  conjunctiva.  It  causes 
hyperemia  of  the  conjunctival  blood  vessels. 

x^nesthesia  is  rapidly  induced,  that  is,  in  from 
one  to  two  miniites.  From  this  standpoint,  in 
comparison  with  cocaine,  a  considerable  saving  of 
time  is  effected.  "One  or  two  drops  of  a  1%  solu- 
tion generally  brought  about  entire  anesthesia  in 
from  forty  to  fifty  seconds;  when  a  second  appli- 
cation was  made,  forty  seconds  after  the  first, 
entire  loss  of  sensation  invariably  followed  in 
thirty  seconds  more."     (Hasket  Derby.) 

"As  holocaine  is  five  times  more  toxic  than 
cocaine,  and  the  effect  of  a  1%  solution  of  holocaine 
is  about  equal  to  5%  solution  of  cocaine,  there 
would  seem  to  be  no  greater  danger  from  the  use 
of  one  than  from  the  other."    (Deane.) 

The  1%  and  3%  solutions  are  the  solutions  most 
commonly  used;  a  few  drops  of  either  of  these 
solutions  instilled  in  the  conjunctival  sac  will 
secure  an  anesthesia  of  that  membrane  and  of  the 
superficial  structures  of  the  eye  in  from  one  to 
three  minutes.     This  anesthesia  lasts  about  ten 


172  GENERAL    AND    LOCAL    ANESTHESIA. 

minutes.  Two  or  three  instillations  at  one  minute 
intervals  may  be  required.  Immediately  after 
instillation,  a  slight  burning,  smarting  sensation 
is  experienced.  This  is  not  lasting;  it  rapidly 
passes  off. 

The  advantages  which  holocaine  possesses  for 
ophthalmic  use  are: 

(a)  Eapidity,  promptitude  of  action. 

(b)  Does  not  dilate  the  pupil. 

(c)  It  does  not  affect  the  accommodation.  No 
unpleasant  blurring  of  vision  follows  its  use. 

(d)  It  does  not  increase  the  intraocular  pressure. 

(e)  It  does  not  impair  the  integrity  of  the  cor- 
neal epithelium.  Holocaine  not  contracting  the 
conjunctival  blood  vessels,  it  causes  neither  bleach- 
ing of  the  eye,  nor  lessening  of  the  lachrymal 
secretion,  nor  drying  of  the  corneal  epithelium. 

(f  )  There  are  no  after  effects.  In  cutting  oper- 
ations, the  increased  hemorrhage  due  to  the  hyper- 
emia which  this  agent  occasions  is  of  service  to 
wash  out  pathogenic  germs  that  may  be  present 
on  the  corneal  or  conjunctival  wound. 

"When  the  surgeon  of  to-day  has  cut  his  finger 
with  a  knife  passed  through  tissues  of  doubtful 
purit}^  he  no  longer  burns  out  the  wound  but 
makes  it  bleed."    (Knapp.) 

(g)  Stability  and  bactericidal  quality  of  solu- 
tions.   Infection  under  the  use  of  holocaine  is  not 


HOLOCAINE.  173 

possible  when  a  proper  antiseptic  technique  is 
observed.  Because  the  solutions  are  bactericidal. 
The  hemorrhage  occurring  under  holocaine  anes- 
thesia is  regarded  by  many  ophthalmologists,  Dr. 
Knapp  among  others,  as  lessening  the  danger  ol 
infection.  The  hemorrhage  has  a  tendency  to 
wash  out  the  bacteria  present  in  the  wound. 

"A  1%  solution  stops  fermentation  and  putri- 
faction  entirely."    (Heinz.) 

It  is  useless  to  add  any  antiseptics  to  solutions 
of  holocaine  with  the  view  of  keeping  them  antisep- 
tic. "Germs  can  not  live  in  solutions  of  holocaine, 
for  it  actually  kills  these  organisms."  (R.  L. 
Randolph.) 

(h)  It  may  be  used  when  cocaine  is  contraindi- 
cated,  as  in  glaucoma.  In  the  performance  of 
iridectomy  in  glaucoma,  it  has  been  found  to  be  of 
special  value.  "In  glaucoma,  dilation  of  the  pupil 
increases  and  contraction  diminishes  intra-ocular 
pressure.  This  long  ago  led  to  the  observation 
that  the  instillation  of  atropine,  cocaine  and  other 
drugs  that  dilate  the  pupil  might  produce  an 
attack  of  glaucoma  in  an  eye  predisposed  to  this 
disease."    (Derby.) 

In  ulcer  of  the  cornea  and  in  all  operations  upon 
the  cornea  it  is  to  be  preferred  to  cocaine,  as  it 
relieves  pain  equally  well  and  it  does  not  impair 
the  integrity  of  the  corneal  epithelium.     It  has 


174  GENERAL    AND    LOCAL   ANESTHESIA. 

no  dessicating  action  on  the  cornea.  "Holocaine 
does  not  interfere  with,  nutrition  of  tissue,  but 
rather  increases  the  blood  supply  and  hastens  heal- 
ing/^   (Wurdemann  and  Black.) 

.The  vaso-constrictor  action  of  cocaine  is  useful 
in  operations  on  vascular  tissue,  but  is  harmful 
in  those  performed  upon  the  cornea  because  of  the 
unfavorable  way  in  which  it  influences  nutrition. 

Holocaine,  owing  to  its  poisonous  nature,  should 
never  be  used  subcutaneously.  Even  in  minute 
doses,  when  administered  internally,  it  is  highly 
poisonous.  (The  poisonous  nature  and  the  mineral 
toxic  dose  of  holocaine  have  been  determined  by 
laboratory  experiments.  There  are  no  reports  of 
fatalities  occurring  in  man  from  the  use  of  holo- 
caine.) Symptoms  of  intoxication  due  to  the  inter- 
nal use  of  holocaine  simulate  those  observed  in 
strychnine  poisoning.  You  will  treat  this  condi- 
tion symptomatically.  As  holocaine  does  not  con- 
tract the  blood  vessels,  operations  under  its  influ- 
ence are  likely  to  be  attended  by  more  hemorrhage 
than  those  performed  under  cocaine.  In  muscle 
operations,  in  pterygia  and  deeper  operations  upon 
the  globe  of  the  eye,  the  tendency  to  more  free 
hemorrhage  is  disadvantageous.  Hemorrhage 
obscures  the  field  of  operation;  it  also  seems  to 
lessen  the  duration  of  the  anesthesia.  This  is 
probably  due  to  washing  out  of  the  anesthetic  by 
the  outflow  of  blood. 


NIRVANINE.  175 

NIRVANINE. 

Nirvanine  is  a  local  anesthetic  agent^  only  one- 
tenth  as  toxic  as  cocaine.  It  has  been  used  in 
children  without  ill  effects.  Its  nse  is  not  attended 
by  any  excitement,  influence  on  respiration,  or 
weakening  of  the  heart's  action.  Owing  to  the 
relative  nontoxicity  of  this  drug,  it  is  of  special 
value  to  secure  anesthesia  of  parts,  the  circulation 
of  which  can  not  be  easily  controlled,  as  in  opera- 
tions in  anal  regions.  Nirvanine  anesthesia  lasts 
longer  than  cocaine  anesthesia. 

For  the  ophthalmic  surgeon,  nirvanine  is  not  a 
serviceable  anesthetic.  Applied  to  the  unbroken 
skin  it  does  not  anesthetize  it.  Applied  to  the 
mucous  membrane  it  is  not  to  be  recommended 
when  it  is  intended  that  anesthesia  should  reach 
deeply  as  in  nose  and  throat  surgery. 

The  field  of  nirvanine  is  in  subcutaneous  and  in 
infiltration  anesthesia.  When  you  wish  to  employ 
subcutaneous,  or  submucous  nirvanine  anesthesia, 
you  can  secure  it  by  employing  the  same  technique 
that  is  employed  in  securing  cocaine  endermic  and 
hypodermic  anesthesia.  For  nirvanine  infiltration 
anesthesia  make  use  of  the  technique  that  is  em- 
ployed for  securing  infiltration  anesthesia  with 
Schleich's  formulae.  There  is  this  difference,  how- 
ever, that  when  you  use  the  Schleich's  formulae 
anesthesia  is  complete  as  soon  as  the  tissues  are 
completely  infiltrated,  while  with  the  nirvanine 


176  GENERAL    AND    LOCAL    ANESTHESIA. 

solutions  from  five  to  eight  minutes  elapse  before 
anesthesia  sets  in. 

Mrvanine  is  being  increasingly  used  by  the 
dental  profession.  For  tooth  extraction,  inject 
your  solution  of  nirvanine  on  either  side  of  the 
tooth  down  to  the  periosteum.  Place  the  fingers 
over  the  punctures  to  prevent  the  solution  from 
running  out  and  then  by  gentle  pressure  assist 
in  dispersing  the  liquid  into  the  surrounding 
tissues.  Wait  three  to  five  minutes  before  extract- 
ing the  tooth. 

Sterilization  by  boiling  does  not  decompose 
nirvanine  solutions  and  does  not  impair  their 
anesthetic  properties.  For  hypodermic  injection 
anesthesia,  the  most  commonly  used  solutions  are 
the  1%,  2%,  3%  and  5%  aqueous  solutions.  For 
infiltration  anesthesia,  a  i%  to  J%  solution  is 
used.  Luxemburger  recommends  that  nirvanine  be 
dissolved  in  normal  salt  solution. 

ORTHOFORM. 

Orthoform  is  a  tasteless,  odorless,  whitish 
powder.  It  is  but  slightly  soluble  in  water;  it 
is  very  soluble  in  alcohol  and  ether.  This  insolu- 
bility in  water  unfits  it  for  hypodermic  use  and 
for  infiltration  anesthesia.  It  is  sterile,  but  is  not 
bactericidal  to  the  germs  of  suppuration.  No 
germs  are  found  in  it  as  it  leaves  the  factory,  and 
the  few  germs  that  may  accidentally  gain  access  to 


ORTHOFORM. 


177 


it  by  careless  exposure  or  by  unclean  contact  are 
either  destroyed  or  lose  much  of  their  virulency. 
In  cases  in  which  an  antiseptic  as  well  as  an  anes- 
thetic action  is  desirable  or  required,  orthoform 
can  be  combined  with  any  of  the  following  anti- 
septic agents:  Iodoform,  dermatol,  aristol,  zinc 
oxide,  calomel.  The  first  four  agents  must  be 
sterilized  before  they  can  be  used  on  wound  sur- 
faces. The  afore-mentioned  agents  are  not  chem- 
ically, pharmaceutically  nor  physiologically  incom- 
patibles  of  orthoform. 

The  drug  when  used  in  therapeutic  doses  is 
non-toxic.  It  has  in  a  few  reported  instances, 
when  applied  too  profusely,  caused  an  eczematous 
condition  of  the  skin  surrounding  the  wound  with 
which  it  had  been  in  too  prolonged  contact.  This 
accident  I  have  never  met  with.  Should  eczema 
occur  after  its  use,  stop  using  the  preparation  for 
two  or  three  days.  If  on  second  trial  eczematous 
lesions  are  again  provoked,  the  drug  is  not  suited 
for  use  in  that  individual  case.  The  drug  has  been 
given  internally  in  doses  of  from  15  to  25  grains 
daily  without  inflicting  any  injury  upon  the  organ- 
ism. 

Orthoform  does  not  act  upon  the  unbroken  skin. 
"The  substance  will  not  act  on  unbroken  skin  nor 
with  certain  reservations  on  intact  mucous  mem- 
brane." (Young.)  On  the  unbroken  mucous 
membrane  of  the  mouth,  naso-pharynx  and  larynx, 


178  GENERAL    AND    LOCAL    ANESTHESIA. 

orthoform  does  not  secure  anesthesia  suitable  for 
surgical  action.  To  produce  anesthesia^,  it  must 
come  in  contact  with  terminal  sensory  nerve-end- 
ings. It  then  produces  in  from  three  to  eight  min- 
utes anesthesia  of  the  surface  to  which  it  has  been 
applied.  This  anesthesia  is  complete  to  pain  only. 
Orthoform  is  chiefly  used  to  secure  absence  of 
pain  in  painful  non-operatiye  conditions  and  after 
operations  in  hyperesthetic  areas.  Its  anesthetic 
action  is  prolonged  for  hours.  We  can  use  ortho- 
form^  either  pure  or  diluted,  as  a  dusting  power 
applied  to  the  open  surface  which  we  wish  to  anes- 
thetize. It  can  be  used  in  alcoholic  solution;  an 
ointment  of  from  10  to  30  per  cent  with  lanolin 
base;  in  emulsion  with  the  yolk  of  egg;  in  10  per 
cent  solution  with  collodion. 

INDICATIOXS  rOR  USE. 

1.  To  relieve  the  pain  of  ulcers,  chancroidal, 
syphilitic,  tubercular,  carcinomatous  or  simple 
chronic  ulcers.  Apply  the  drug  to  the  surface  of 
the  ulcer  and  insure  its  retention  there.  Ortho- 
form  coming  in  contact  with  the  exposed  nerve 
endings  secures  a  marked  and  often  a  complete 
suppression  of  the  pain.  It  does  not  interfere  with 
the  regeneration  of  tissues  and  exerts  no  unfavora- 
ble influence  on  the  economy.  It  secures  a  long 
anesthesia.  If  exudation  is  abundant,  use  it  in  the 
form  of    an    ointment.     An    abundant    exudate 


INDICATIONS   OF   ORTHOFORM.  179 

washes  off  the  powder.  Owing  to  the  innocuous- 
ness  of  orthoform,  repeated  applications  are  not 
harmful.  In  rectal  chancroids,  in  rectal  car- 
cinoma, a  10  per  cent  orthoform  suppository  will 
do  away  with  the  pain,  and  will  enable  the  patient 
to  dispense  with  the  use  of  opium,  with  its  allied 
constipating  effects  and  antagonism  to  assimila- 
tion. Non-toxicity  of  orthoform  is  demonstrated 
by  the  fact  that  in  a  case  of  inoperable  carcinoma 
two  ounces  were  applied  weekly  without  any  ill 
effects.  As  a  local  application  to  corneal  ulcers, 
to  canker  sores,  and  to  herpetic  ulcers,  it  is  very 
satisfactory.  It  may  be  used  in  carcinoma  of  the 
tongue  to  make  eating  painless.  Dusting  ortho- 
form  upon  painful,  indolent,  varicose  ulcers  ren- 
ders them  comparatively  painless.  Avoid  eczema 
by  not  using  orthoform  too  freely  in  the  beginning 
and  by  the  application  of  a  thick  zinc-oxide  oint- 
ment around  the  ulcer. 

2.  To  relieve  the  soreness  and  pain  resulting 
from  cutting,  snaring  or  cauterizing  operations 
upon  the  nasal  cavity.  Powder  can  be  applied  to 
the  field  of  operation,  or  orthoform  gauze  can  be 
packed  lightly  into  the  cavity.  Orthoform  gauze 
can  be  packed  in  wound  sinuses. 

3.  In  tubercular  laryngeal  ulcerations,  ortho- 
form  is  of  value  to  relieve  pain  and  to  cause  a  dis- 
appearance of  the  difficulty  of  swallowing.  In  the 
larynx,  orthoform  is  best  applied  with  an  insuf- 


180  GENERAL    AISTD    LOCAL    ANESTHESIA. 

flator.  Use  about  five  grains  at  each,  insufflation. 
It  enables  tuberculous  patients  to  take  nourish- 
ment, thereby  retarding  the  progress  of  the  disease. 
The  following  emulsion  is  recommended  in  laryn- 
geal ulcers  by  Freudenthal: 

Menthol  la 

01.  amygdalae  dulc 30. 

Vitelli  ovi.  about  two  yolks. .  .   30. 

Orthoform   12.5 

Aq.   dest.   q.   s.   ad 100. 

M.  et.  ft.  emulsio. 
In  using  this  emulsion  in  the  larynx,  use  an 
ordinary  laryngeal  syringe. 

4.  As  an  application  for  burns,  be  they  thermic 
or  chemical,  when  there  is  an  exposure  of  nerve 
terminals.  It  secures  an  almost  immediate  cessa- 
tion of  pain.  This  anesthesia  lasts  about  twelve 
hours.  "Almost  immediately  after  its  applications 
for  burns,  even  if  they  be  deep,  the  pain  ceases." 
(Maygrier.) 

5.  As  an  application  to  operation  wounds.  To 
lessen  the  after  pains  of  an  operation.  After  the 
removal  of  the  faucial  tonsils  if  orthoform  be  ap- 
plied to  the  cut  surfaces,  the  patient  can  eat  solid 
food  without  pain  being  excited.  After  circum- 
cision, after  cauterization,  after  operation  for 
hemorrhoids,  etc.,  the  local  use  of  orthoform  is  pal- 
liative. For  the  relief  of  severe  pain  following  the 
application  of  the  various  caustics  or  the  actual 
cautery,  orthoform  powder  or  ointment  applied  to 


USE    OF   ORTHOFORM.  181 

the  raw  surface  and  covered  with  the  gauze  dress- 
ing is  efficacious. 

6.  Upon  excoriations  as  in  those  that  are  present 
around  artificial  ani,  as  an  application  for  bed- 
sores, etc. 

7.  Upon  lacerated  wounds.  I  have  used  it  fre- 
quently in  crushing  wounds  of  the  finger.  Painful 
sinuses  can  be  tamponed  with  orthoform  gauze, 
it  can  be  used  upon  painful  perineal  and  vulvar 
lacerations  following  delivery. 

8.  In  painful  hemorrhoids,  the  application  of  a 
10  per  cent  ointment  about  ten  or  fifteen  minutes 
before  going  to  stool  makes  the  latter  painless.  In 
cases  of  anal  fissure  and  other  painful  lesions  of 
anus  and  rectum,  its  use  is  serviceable. 

9.  Upon  the  exposed  pulp  of  carious  teeth; 
after  teeth  extractions.  For  dental  caries  intro- 
duce into  the  dental  cavity,  previously  dried,  a 
plug  of  cotton  impregnated  with  the  following 
preparation: 

E.     Orthoform gr.  15 

Acid,  carbolici gr.  15 

Camphorae, 

Chloral  hydrate,  aa gr.  40 

10.  In  painful  fissured  nipples.  Apply  to  the 
nipple,  ten  minutes  previous  to  putting  the  child 
to  the  breast,  a  pledget  of  gauze  impregnated  with 
a  saturated  solution  of  orthoform.  After  several 
applications,  nursing  will  in  most  cases  cease  to 


183  GENERAL    AND    LOCAL    ANESTHESIA. 

be  painful.  You  get  the  anesthetic  action  of  the 
orthoform  and  you  also  get  the  antiseptic  action  of 
the  alcohol.  Maygrier  used  this  treatment  in  forty 
cases  of  fissured  nipples;  in  all  he  secured  com- 
plete analgesia  of  the  breast  while  at  rest.  Pain 
during  nursing  was  in  all  cases  markedly  dimin- 
ished. In  the  majority  of  the  cases  it  had  disap- 
peared entirely. 


INDEX. 


Abdominal  Operations, 
27. 

Accidents  of  Anesthesia, 
87. 

Adenoids,  28. 

Age,  Selection  of  Anes- 
thetics for,  20. 

Alcoholism,  Anesthetic 
in,  25. 

Allis  Inhaler,  82. 

Anesthesia,  General,  7. 

—  in  Convulsions,  13. 

—  duration  of,  54- 

—  incomplete,  59. 

—  infiltration,   155. 

—  local,  112. 

—  precautions  in,  43. 
Anesthetics,    "Crowding," 

48. 

—  Diagnostic,  Uses,  11. 

—  in  Obstetrics,  13. 

—  Rules  for  Administra- 
tion, 35- 

—  Therapeutic    Uses,    12. 

—  Selection  of,  18. 

—  Time  of  Administra- 
tion, 38. 

—  in   Surgery,    17. 
Anesthetist,   Attention  to 

Duty,  49- 

—  Cleanliness  of,  36. 

—  Position  of,  38. 

—  Outfit  of,  35. 


Antipyrin,   119. 
Asphyxia,  88, 

Beta-Eucaine,   113. 
Blood,    Color    of,    60. 
Braun's  Formula,   159. 
Breathing,     Encouraging, 

56. 
Bromide  of  Ethyl,  97. 
Brucine,   113. 

Carbolic  Acid,   118. 
Childbirth,        Anesthetics 
in,  14. 

—  Chloroform  in,   14. 
Chloroform,   Points   Con- 
cerning, TJ. 

—  Purity  of,  Z^- 
Circulation   during  Anes- 
thesia, (£. 

Circumcision     by      Local 

Anesthetic,  117. 
Climate   and   Anesthetics, 

21, 
Cocaine,  130. 

—  Accidents  with,  154. 

—  as  an  Aid  to  Diagnosis, 
143. 

—  in  Genito-Urinary  Sur- 
gery, 141. 

—  Method  of  Using,   149- 

—  in    Mouth    and    Nose, 
137. 

—  in  Ophthalmology,  I34- 


184 


INDEX. 


—  in  Otology,   139. 

—  properties  of,  131. 

—  as  a  Therapeutic  Agent, 
144. 

Danger,  Signs  of  with 
Chloroform,  81. 

Diabetes  Millitus,  Proper 

Anesthetic,  24. 
Dress,  44. 

Eclampsia,  Chloroform 
in,  16. 

Environment  and  Anes- 
thetic, 21. 

Esmarch  Inhaler,  80. 

Ether  Accidents,  88. 

—  Administration    of,    83. 

—  Pneumonia,  85. 

—  Points  Concerning,  82. 

—  Purity  of,  36. 

—  Time  Required,   84. 
Ethyl    Bromide,    97. 

—  Bromide,^  Advantages 
of,  100. 

—  Bromide,  Disadvan- 
tages, 102. 

—  Bromide,  Technique  of, 
104. 

—  Chloride,  129. 
Eucaine,   113. 

Face,   Care   of,  44,  45. 
Guaiacol,  118. 

Goitre,  Chloroform  in,  25. 

Head,    Position    of,    53. 
Headache      after      Anes- 
thesia, 95. 


Heart's    Action,    66. 

Holocaine,   169, 

Hydrocule,  Local  Anes- 
thesia, 118. 

Inhaler,  AUis,  82. 

—  Esmarch,  80. 
Infiltration        Anesthesia, 

155. 

Labor,      Chloroform      in, 

13. 
Liver   Impairment,  25. 
Local  Anesthesia,  112. 

Advantage  of,   120. 

Contra-indicated,  124. 

—  Anesthetics,  113. 
Choice  of,  15. 

Morphine  in  Anesthesia, 
49. 

Mortality  from  Anes- 
thetics, 19. 

Muscular  System,  68. 

Neck,   Operations   in,   28. 
Nirvanine,  175. 
Nervous  System,  70. 
Nitrous    Oxide,    28. 

Obstetrics,  Anesthetics 
in,  13. 

Operation,   Nature  of,  26. 

Ophthalmology,     Chloro- 
form in,  26. 
Orthoform,  176. 

Paralysis,  Post  -  Anes- 
thetic, 95. 


INDEX. 


185 


Patient,  Age  of,  20. 

—  Care  of  During  Oper- 
ation, 44,  45,  50,  51. 

— Physical  Condition  of, 
22. 

—  Posture  of,  30. 

—  Preparation  of,  31. 

—  Respiration   of,   56,   61. 

Phthisis,  Proper  Anes- 
thetic, 24. 

Pneumonia  from  Ether, 
85. 

Position,    Change   of,   51. 

—  of  Head,  53. 

Post  -  Anesthetic  Treat- 
ment,  86. 

Posture  of  Patient,  30, 
39. 

Preparation  of  Patient, 
31. 

Pulse  during  Anesthesia, 
66. 

Pupil,  Observation  of,  74. 


Rectal   Surgery,   29. 

Reflexes      during     Anes- 
thesia, 64,  72. 

Refrigeration,  119,  127. 

Respiration,  Artificial,  90. 

Respiratory  Diseases,   An- 
esthetic in,  24. 

Room  Used,  52. 

Schleich's  Formulas,  160. 
Struggling,   55. 

Strychnin      and      Stimu- 
lants, ^^. 
Syncope,  89. 

—  Measures    to    Combat, 
91. 

Teeth,  Extraction  of,  28. 
Tongue,  Care  of,  54,  58. 
Tracheotomy,  26. 

Vomiting      after      Anes- 
thesia, 93. 

—  during   Anesthesia,    57. 


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